Download:
pdf |
pdfATTACHMENT D2: NORC IRB PACKAGE
Institutional Review Board Certification
Exemption
Principal Investigator / Project Director: Nancy Pindus/Carol Hafford
Department: Economics, Labor, and Population Studies
IRB Protocol Number: 12.10.04
Project Number: 6954
Protocol Title: Study of the Food Distribution Program on Indian Reservations
This certifies that the research activities regarding human subjects in the protocol
described above have been found to be exempt under exemption category 2 by the
NORC Institutional Review Board (IRB00000967), under its Federalwide Assurance
#FWA00000142, which is valid through August 16, 2013.
Any amendments or other changes to this protocol must be submitted for review by
the IRB, and all adverse events must be reported to the IRB.
Please notify the IRB when your study has closed.
__________________________
Karen H. Grigorian, IRB Chair
55 East Monroe Street, Chicago, Illinois 60603
10.24.2012
Date
Phone: 773-256-6000
www.norc.uchicago.edu
Rev. 8/2012
IRB APPLICATION FORM—INITIAL REVIEW
IRB Use Only
IRB Protocol #
To check off the “check boxes” in this document, double-click on a check-box, and select
“Checked” under the “Default value.”
All IRB forms, as well as FAQs and other guidance, are available on the IRB webpage on the NORC
intranet at http://intranet.norc.org/resources/irb/default.aspx
NOTE: If you are seeking a Limited Activities Determination (LAD) from the IRB, do NOT complete this form; instead, fill
out the LAD Application Form that is on the IRB intranet webpage. The LAD is not a type of IRB approval and is not a
substitute for IRB approval. Rather, the LAD is used in circumstances where complete, definitive plans for human subjects
research activities are not fully described in the federal funding application/proposal because significant
development work (such as development of specific research procedures, questionnaires, or
research instruments) still must occur before the research can begin. The purpose of the LAD is to allow researchers to
have access to funding to begin aspects of the research that do not involve human subjects. No human subjects research
activities can occur until the IRB has granted exempt status or has reviewed and approved the research.
1. PROJECT SUMMARY INFORMATION
1.1
Project Number (If the project does not yet have a PN but requires IRB review, submit the proposal number or
the charge code for the department overhead.)
6954
1.2
Study Title
Study of the Food Distribution Program on Indian Reservations
1.3
Contact information for study personnel:
Principal Investigator:
Institution:
Email Address:
Project Director:
(N/A if same as PI)
Institution:
Email Address:
Nancy Pindus
Urban Institute
[email protected]
Carol Hafford, PhD
NORC
[email protected]
Contact Person:
(N/A if same as PD)
Financial Analyst:
1.4
Veronica Viramontes
NORC departments responsible for this study
NORC Department:
Other (Specify):
Economics, Labor, and Population Studies
1
NORC IRB Application for Initial Review
1.5
Rev. 6/2012
Who is funding the study? (If NORC is a subcontractor, include both the names of the original funding agency
and the prime institution which has subcontracted out to NORC.)
US Department of Agriculture, Food and Nutrition Service
Urban Institute is the prime contractor
1 .6
Is NORC the awardee institution for a federal grant for this study ?
Yes. If Yes, you must submit a copy of the grant application or proposal to the IRB with your
protocol submission
No.
1.7
Is this research proposal being reviewed by one or more IRBs at institutions other than NORC?
Yes. Attach copy of IRB approval if this study has been reviewed and approved by another IRB
The Urban Institute’s IRB protocol is attached as Appendix N.
No.
NOTE: If your study is funded by certain federal agencies, there may be special requirements beyond the
regulations contained in 45 CFR Part 46 that must be complied with. If your research if funded by
the Department of Defense, U.S. Department of Education, U.S. Department of Energy, the
U.S. Environmental Protection Agency, U.S. Department of Justice/Bureau of Prisons, or
the U.S. Department of Justice/National Institute of Justice, please be sure to check with
your funding agency concerning additional requirements that apply to conducting human subjects
research funded by those agencies. Other federal agencies may also have additional requirements
pertaining to human subjects’ research protections. Guidance is posted on the IRB webpage on the
intranet concerning additional requirements pertaining to research funded by the U.S. Department of
Education (ie, the PPRA and FERPA statutes).
1.8
Does your study need to be registered on the clinicaltrials.gov website and/or comply with the
International Committee of Medical Journal Editors (ICMJE) registration requirements?
Yes.
No.
NOTE: Under federal law, certain clinical trials must be registered on the clinicaltrials.gov website, and the
consent form for such studies must contain certain standard language explaining that the trial is
registered on clinicaltrials.gov. For further guidance on clinical trial registration requirements, see
the IRB webpage on the Intranet.
2
NORC IRB Application for Initial Review
Rev. 6/2012
2. TRAINING REQUIREMENTS
It is the responsibility of the Principal Investigator/Project Director to ensure that all individuals
involved in the conduct of human subjects research complete human subjects protection training
prior to submission of the project to the IRB for review, and when new personnel join a project
after initial IRB approval. The requirement to undergo human subjects protection training applies to all
persons with a significant role in the conduct of the research, including those individuals designated
as:
Principal Investigators and Co-investigators,
Individuals named on a study grant or contract proposal,
Individuals named as a contact person in the informed consent document(s) or recruitment materials for
research
Individuals who obtain informed consent from prospective participants in research, and
Individuals who obtain and analyze individually identifiable data
Proof of human subjects training does NOT need to be submitted for telephone and field
interviewers working on a research project.
Per NORC IRB policy, human subjects protection training must be renewed every 5 years. The
options for renewing training are discussed on the IRB webpage on the Intranet.
2.1
Please list in the table below the names of all investigators and other key research
personnel for this project (ie, the personnel who will have a significant role in the conduct of this
research project--you do NOT need to list field/phone interviewers). If investigators/key research
personnel are not NORC employees or affiliated with NORC, please indicate their institutional
affiliation:
Investigators and other key research
personnel:
Carol Hafford
Suzanne Bard
Steven Pedlow
Athena Diaconis
Nancy Pindus
Diane Levy
Walter Hillabrandt
2.2
Institutional Affiliation (if not employed
by/affiliated with NORC)
NORC
NORC
NORC
NORC
Urban Institute
Urban Institute
Support Services International
Have all investigators and key research personnel engaged in this research project completed
training on the conduct of human subjects research within the past 5 years?
Yes.
No.
If any investigators or key research personnel on this project have not previously submitted a human
subjects protection training completion certificate to the NORC IRB, that certificate must be emailed to
[email protected] before the investigator/personnel can engage in human subjects research.
3
NORC IRB Application for Initial Review
Rev. 8/2012
3. FINANCIAL CONFLICT OF INTEREST
3.1
Is this study funded by a U.S. Public Health Service Awarding Component* or by the
National Science Foundation?
Yes.
No.
*The U.S. Public Health Service Awarding Components are: AHRQ (Agency for Healthcare Research
and Quality); ATSDR (Agency for Toxic Substances and Disease Registry); CDC (Centers for Disease
Control and Prevention); FDA (Food and Drug Administration); IHS (Indian Health Service);
HRSA (Health Resources and Services Administration); NIH (National Institutes of Health); and
SAMHSA (Substance Abuse and Mental Health Services Administration)
If you answered Yes to Question 3.1, go on to Question 3.2. If you answered No, proceed to
Section 4 of this form.
3.2
If this project is funded by a Public Health Service Awarding Component or by the NSF,
have all personnel on this project who are involved as an “Investigator” (see definition of
“Investigator” below) completed the NORC Significant Financial Interest Disclosure Form?
Yes.
No.
For purposes of financial conflicts of interest, “Investigator” is defined as the project director or principal
investigator and any other person, regardless of title or position, who is responsible for the design, conduct,
or reporting of research, or proposed for such funding, which may include, for example, subrecipients,
subcontractors, collaborators, or consultants. NORC considers the role, rather than the title, of those
involved in research and the degree of independence with which those individuals work. If the project involves
Investigators who are subrecipients, subcontractors, collaborators, or consultants to NORC, and those individuals
are following NORC’s FCOI Policy, the NORC SFI Disclosure Form must be submitted by those Investigators.
NOTE: if personnel who are working on this project as an Investigator have not filed the Significant Financial
Interest Disclosure Form, that form is available on the FCOI page on the NORC Intranet at
http://intranet.norc.org/resources/FCI/default.aspx, and must be completed and e-mailed to [email protected] before
the IRB can approve this project.
3.3
If this project is funded by a Public Health Service Awarding Component, have all personnel working
on the project in the role of an Investigator completed the required Financial Conflict of Interest
training?
Yes.
No.
NOTE: NORC personnel who are Investigators on a PHS-funded research project must complete FCOI training prior
to doing any work on the project. The FCOI training is available through the CITI website (www.citiprogram.org).
For subrecipients/subcontractors/collaborators/consultants to NORC who are Investigators on PHS-funded projects
and are following NORC’s FCOI Policy, the Investigator must either notify NORC if the Investigator has already
received FCOI training at another institution or complete the NIH’s FCOI tutorial on the NIH website. Further
information about FCOI training is available on the FCOI page on the NORC intranet at
http://intranet.norc.org/resources/FCI/default.aspx
4
IRB Application for Initial Review
Rev. 8/2012
4. DETERMINATION OF HUMAN SUBJECTS RESEARCH
NOTE: All projects that involve human subjects research must be reviewed and approved by the IRB before
recruitment and data collection may start.
As defined in the HHS regulations at 45 CFR 46.102:
“Human subject” means a living individual about whom an investigator (whether professional or
student) conducting research obtains
(1) Data through intervention or interaction with the individual, or
(2) Identifiable private information.
“Private information” includes information about behavior that occurs in a context in which an
individual can reasonably expect that no observation or recording is taking place, and information
which has been provided for specific purposes by an individual and which the individual can
reasonably expect will not be made public (for example, a medical record). Private information must
be individually identifiable (i.e., the identity of the subject is or may readily be ascertained by the
investigator or associated with the information) in order for obtaining the information to constitute
research involving human subjects.
“Research” means a systematic investigation, including research development, testing and
evaluation, designed to develop or contribute to generalizable knowledge (that is, to better
understand others beyond the study sample).
4.1
Does the activity meet the definition of research?
Answer Yes or No each of the following questions.
Note to IRB: Please note that the study comprises two data collection activities, a Case Record
Review and a Participant Survey. Both are discussed separately in this and subsequent sections.
A: Case Record Review
4.1.1
The activity employs a systematic approach involving predetermined methods for studying a
specific topic, answering a specific question, testing a specific hypothesis, or developing a
theory.
Yes.
No.
4.1.2
The activity is intended to contribute to generalizable knowledge by extending the results
beyond a single individual or an internal unit.
Yes.
No.
B: Participant Survey
4.1.3
The activity employs a systematic approach involving predetermined methods for studying a
specific topic, answering a specific question, testing a specific hypothesis, or developing a
theory.
Yes.
No.
5
NORC IRB Application for Initial Review
4.1.4
Rev. 8/2012
The activity is intended to contribute to generalizable knowledge by extending the results
beyond a single individual or an internal unit.
Yes.
No.
4.2
Does the activity involve human subjects?
Answer Yes or No each of the following questions.
A: Case Record Review
4.2.1a The investigator obtains specimens or data through intervention or interaction with a living
individual (e.g., interviews, surveys, physical procedures, manipulations of the subject’s environment,
private or limited access internet sites, or any other direct contact or communication with a subject).
Yes.
No.
4.2.2a The investigator is obtaining identifiable private information about living individuals (e.g.,
chart reviews, lab studies on tissues or specimens, information from data or tissue repository).
Yes.
No. Demographic, household composition (age, relation to head of household) and
economic resource information will be abstracted from FDPIR certification forms that are used to
determine program eligibility. No identifiable information will be abstracted.
4.2.3a The data or specimens are received by or provided to the investigator with identifiable
private information.
Yes.
No. FDPIR eligibility forms are maintained as paper files only. It would impose a
considerable burden on the tribe or Indian Tribal Organization (ITO) to duplicate the case records
and redact names, addresses, etc. in order to obscure this information from the researchers
abstracting the information (as described in response to 4.2.2a above). We will not be abstracting
any of the following information that is present on the case record:
Name, phone, mailing address, city, county
Household members (name, birthday, SSN)
Prior application for or receipt of food stamps (SNAP)
Disqualification
A sample FDPIR eligibility form is provided as Appendix I and shows in a comment box which data
fields will not be abstracted.
4.2.4a The data or specimens are coded and the investigator has access to a link that would allow
the data or samples to be identified.
Yes.
No.
6
NORC IRB Application for Initial Review
Rev. 8/2012
B: Participant Survey
4.2.1b The investigator obtains specimens or data through intervention or interaction with a living
individual (e.g., interviews, surveys, physical procedures, manipulations of the subject’s environment,
private or limited access internet sites, or any other direct contact or communication with a subject).
Yes.
No.
4.2.2b The investigator is obtaining identifiable private information about living individuals (e.g.,
chart reviews, lab studies on tissues or specimens, information from data or tissue repository).
Yes.
No.
4.2.3b The data or specimens are received by or provided to the investigator with identifiable
private information.
Yes. Each tribe or ITO will provide a list of names with mailing addresses and phone
numbers will be provided for contacting respondents.
No.
4.2.4b The data or specimens are coded and the investigator has access to a link that would allow
the data or samples to be identified.
Yes.
No.
4.2
Did you check “No” to all of the questions in Part A or Part B above (that is, you indicated that your study
either does not constitute research or does not involve human subjects)?
NOTE to IRB: Does this refer to questions 4.1 and 4.2 above?
A: Case Record Review
Yes.
No.
STOP and do not complete the remainder of this form. Sign at the end and submit this
form to the IRB. The IRB will review your protocol and notify you if your project does not
constitute human subjects research.
Complete the remainder of this form.
B: Participant Survey
Yes.
No.
STOP and do not complete the remainder of this form. Sign at the end and submit this
form to the IRB. The IRB will review your protocol and notify you if your project does not
constitute human subjects research.
Complete the remainder of this form.
7
NORC IRB Application for Initial Review
Rev. 8/2012
5. SUMMARY OF PROPOSED RESEARCH ACTIVITIES
5.1
Describe the objective(s) of the proposed research including purpose, research question, hypothesis
and relevant background information, etc.
OVERVIEW
The Study of the Food Distribution Program on Indian Reservations (FDPIR) will provide a
nationally representative description of participants and tribal programs and will assist the US
Department of Agriculture, Food and Nutrition Service (USDA/FNS) in better understanding the
recent decline in program participation. The project team, comprising the Urban Institute, NORC,
and Support Services International, will select a nationally representative sample of 832 current
participants in 25 FDPIR programs.
There are three phases of data collection: case record review, participant survey, and program
site visits. NORC will conduct the case record review and survey. For this sample of participants,
case record reviews and telephone or in-person interviews will be conducted. Topics for the case
record review include household characteristics, employment, economic hardship, and FDPIR
eligibility. Topics covered in the survey are food storage and preparation, FDPIR contribution to
the household’s food supply, access to the FDPIR program and access barriers, food costs,
participation in FDPIR and other food assistance programs, nutrition education and other healthrelated services, and satisfaction with the program. The consultation and design phase of the
study began in January 2012. The study sample was drawn in September 2012. Consultations
with leaders of the sampled tribes and ITOs will take place in late 2012 and early 2013. Data
collection will occur in 2013. The Final Report will be disseminated in September 2014.
CASE RECORD REVIEW:
The purpose of the case record review is to obtain information that will describe current program
participants and their characteristics. This will include household composition, income sources,
and other available resources or public benefits. The case record review will occur at 25 sampled
sites. About 32 records will be reviewed at each site. The case record review will occur onsite at
tribal FDPIR offices. Information will be abstracted from the case records. The case record review
will be conducted by Bethesda-based NORC staff.
PARTICIPANT SURVEY
For each household sampled in the case records, a 45 minute interview will be conducted. On
average, 32 interviews will be conducted per site, with more in the larger programs. Most of the
interviews will be conducted by phone and the remaining will be in-person. Participants will
receive a letter about the study in advance of being contacted. The letter and materials will
include a toll free number for any questions that they have. Each participant will receive an
incentive worth $25.
It is possible that a participant may decline to participate in the interview himself/herself for
cultural reasons and wish to have another person (i.e., a Proxy) speak on his/her behalf. To this
end, we have provided scripts for informed consent for the Proxy (who would then receive the
incentive). See Appendix H. (Clarification added 10/23/12)
NORC field interviewers will conduct the participant survey and work closely with tribal leaders
and FDPIR programs to implement the study procedures. The participant survey will be managed
by Chicago-based NORC staff and administered by field interviewers.
PROGRAM SITE VISITS
Site visits and interviews with tribal leaders and program staff will be conducted 17 of the 25
sites. The visits will include three types of activities: 1) interviews with program administrators,
staff and service providers; 2) visits to the FDPIR programs to observe facilities related to client
enrollment, warehouses, and food distribution; and 3) discussion groups with program clients and
potential clients. The Urban Institute and SSI will conduct the site visits.
8
NORC IRB Application for Initial Review
5.2
Rev. 8/2012
Describe the tasks subjects will be asked to perform. Attach surveys, instruments, interview questions,
focus group questions etc. Describe the frequency and duration of procedures, psychological tests, educational
tests, and experiments; including screening, intervention, follow-up etc. (If you intend to pilot a process before
recruiting for the main study, explain.)
Case Record Review: Subjects will not participate in the abstraction process. The case record
review form is attached as Appendix G.
Participant Survey: Participation in a telephone or in-person survey in 25 randomly-selected
Native American Reservations and Tribal Service Areas (approximately 32 respondents at each
site). Additional interviews will be conducted at the larger reservations. These interviews will be
conducted by trained NORC interviewers. The tasks will include gaining cooperation and
interviews with the households that receive part of their food supply from FDPIR. Participants will
respond one time only to a series of questions during a 45-minute interview. The draft participant
survey is attached as Appendix H. The interview topics are noted in 5.1 above. There will be no
other requests of this group. As noted above, if a Proxy is designated, then s/he will respond to
the interview questions on the program participant’s behalf. See Appendix H. (Clarification added
10/23/12).
Pretest: Both the case record review and the participant survey will be pilot-tested in October
2013 with two non-sampled tribes or ITOs. There will be no other requests of these tribes.
5.3
How many months do you anticipate this research study will last from the time final approval is
granted?
24 months
6. ANALYSIS OF EXISTING DATA, DOCUMENTS, RECORDS & SPECIMENS
6.1
Will your project involve analysis of existing data sets, documents, records and/or specimens (that is,
data, documents, records, or specimens that were in existence prior to IRB review of this study and that were
collected for purposes other than this proposed research)?
A: Case Record Review
Yes.
No. STOP, skip the remainder of questions in this Section, and go to Section 7.
B: Participant Survey
Yes.
No. STOP, skip the remainder of questions in this Section, and go to Section 7.
6.2
If your project involves analysis of existing data sets, explain which data sets you plan to
analyze; whether the data sets are public use data sets, restricted access data sets, or another type
of data set; and who holds the data set.
A: Case Record Review
As described above, the existing records that will be examined for the case record review are the
eligibility forms that are filled out by program applicants in order to participate in the FDPIR
program. All records are maintained as paper files. Each tribe or ITO maintains the records as part
of its federally-approved program and according to strict program implementation guidance issued
by USDA/FNS. A sample form is provided as Appendix I.
9
NORC IRB Application for Initial Review
6.3
Rev. 8/2012
Do the data or specimens contain direct or indirect identifiers linked to subjects (identifiers
can include names, social security numbers, medical record numbers, or other codes that permit
data or specimens to be linked to living individuals)?
Yes.
No. There will be no direct or indirect identifiers linked to the subjects for the case record review.
There is no linkage between the subject files reviewed in the case record review and responses to
the participant survey (i.e., they are mutually exclusive).
NOTE: OHRP considers data to be coded if (1) identifying information (such as name or social security
number) has been replaced with a number, letter, symbol, or combination thereof (i.e., the code),
and (2) a key to decipher the code exists, enabling linkage of the identifying information to the
private information or specimens.
6.4
If you are conducting analysis of existing data sets, and the data contain a coding system, is there
an agreement in place between the investigators and the holder of the key prohibiting release of
the key to the investigators under any circumstances, until the research subjects are deceased; or
other legal requirements prohibiting the release of the key to the investigators, until the research
subjects are deceased?
Yes.
No. This is Not Applicable to the case record review.
7. PARTICIPANT POPULATION
This section pertains to both the Case Record Review and Participant Survey
7.1
Expected number of participants.
998 for the case record review. 832 for the participant survey (based on an 80% response rate)
7.2
Expected Age Range.
Check all that apply.
0-7. Include a parental consent form.
8-17. Include a child’s assent form and a parental consent form.
18-64.
65 and older.
NOTE: If this study proposes to include “Children” (anyone less than 18 years old), also complete and
submit Appendix C–Research that Involves Children.
7.3
Describe the criteria for inclusion and exclusion of subjects in this research study.
Research subjects are current participants in the FDPIR program for the particular reference
month during which data will be collected (likely to be May 2013). Non-participants for the
reference month will not be selected.
A random sample will be drawn using the Household Issuance History report maintained
electronically by each tribe/ITO. Each tribe will draw the sample using the specifications provided
by NORC. The sample drawn for the case record review and the participant survey uses the same
sample frame and will result in the same set of respondents:
For the Case Record Review the tribe/ITO will draw the sample from the Household
Issuance History. The case files will be pulled from the programs files prior to NORC’s onsite visit and be available for review.
10
NORC IRB Application for Initial Review
Rev. 8/2012
Using the sample drawn for the Case Record review, the tribe will provide NORC with a list
of names and addresses in order to establish contact with subjects for the Participant
Survey. The FDPIR Participant Survey respondents are selected from the case record
reviews.
See the flow chart in Appendix O for a graphic representation of this process.
NOTE: For NIH-funded research, NIH is mandated by federal law to ensure that women and minorities be
included in clinical research. Clinical research includes patient-oriented research; epidemiologic and
behavioral studies; and outcomes research and health services research. Detailed information on
NIH requirements concerning inclusion of women and minorities in clinical research is available on
the NIH website at http://grants.nih.gov/grants/funding/women_min/women_min.htm
7.4
Location of subjects during research activity or location of records to be accessed for research.
Check all that apply.
Elementary/Secondary Schools. Specify:
Prisons/Halfway houses. Complete and submit Appendix D, and specify:
International Location. Complete and submit Appendix F, and specify:
Other special institutions. Specify:
Case Record Review: Case records are maintained in tribal or ITO program offices.
Participant Survey: Some subjects may be interview in their homes or in a private
office on tribal premises.
8. RECRUITMENT
A: Case Record Review
8.1a
Describe the recruitment process to be used for each group of subjects. Attach a copy of any and all
recruitment materials to be used e.g. advertisements, bulletin board notices, e-mails, letters, phone scripts, or
URLs.
This does not apply to the Case Record Review.
8.2a
Describe the compensation/incentive for participation (if any) that research subjects will receive and
circumstances under which payment will be prorated.
This does not apply to the Case Record Review.
8.3a
Are subjects chosen from records?
Yes. Specify who gave approval for use of the records: Tribal Leaders will give approval
through the Tribal Resolutions.
No.
8.3.1a If yes, are records “private” medical or student records?
Yes.
Provide the protocol, consent forms, letters, etc. for securing consent of the
subjects of the records. Written documentation for the cooperation/permission
from the holder or custodian of the records should be attached.
No.
11
NORC IRB Application for Initial Review
Rev. 8/2012
B: Participant Survey
8.1b
Describe the recruitment process to be used for each group of subjects. Attach a copy of any and all
recruitment materials to be used e.g. advertisements, bulletin board notices, e-mails, letters, phone scripts, or
URLs.
TRIBAL RECRUITMENT
CONTACT PERSON: Each tribe will be assigned a NORC contact person (Project Director or
Survey Director) for the outreach efforts. They will be the main contact with the site.
Before any contact begins, each tribal leader and FDPIR program director will receive a
letter from USDA/FNS officials and a joint Urban Institute/NORC letter (see Appendices
L2 and L3 below).
MATERIALS:
o Advance letters and materials for the tribal officials and households contain the
NORC IRB contact information and the telephone number and email address of the
NORC Project Director.
o Tribal leaders are free to distribute the study brochure (Appendix K below).
o The NORC website provides a description of the study, the project team, contact
information, and a link to the Tribal Affairs office of USDA/FNS, the study sponsor:
http://www.norc.org/Research/Projects/Pages/the-study-of-the-food-distributionprogram-on-indian-reservations.aspx
TOLL-FREE TELEPHONE: In addition, the project will have a toll-free number on all
materials which will be answered by a real person. If the toll-free number is busy, the
caller can leave a message and a callback will take place the same day.
SUBJECT RECRUITMENT
COMMUNITY DISCLOSURE: As part of the community disclosure process, and in order to
assure that the respondents will be comfortable with participating in the participant
survey, tribally-directed outreach and pre-planning will include, whenever possible,
community information sessions, newspaper articles, radio announcements, and postings
on tribal web site to help the community become familiar with the project.
The respondents will want to know whether or not we have tribal permission to interview
on tribal lands or contact household by phone. The interviewers will be well versed in how
permission was received and from whom. It is expected that many sites will give us a
tribal referendum (resolution) number to either relay by phone or present at the door. In
other cases the respondents will be provided with the name of a tribal contact or other
tribal official. We plan to request endorsement letters from the Tribes during the outreach
process.
SELECTION: Survey participants will be randomly selected for participation. Materials for
gaining cooperation include an advance letter, phone script, and brochure. Tribally-specific
recruitment materials may be developed. Each household will be mailed an advance letter
that will include a description of the study, Urban Institute Principal Investigator, and
NORC Project Director contact information. It will be clearly stated that the household will
be contacted by a NORC interviewer. Also included will be the time commitment required.
The interviewers will have a supply of the advance letters in case someone does not
remember receiving the mailed letters. A brochure will also be shared with community
members and households. The advance letter to the respondent and brochure are
provided in Appendix J and K, respectively.
DISCLOSURE: Respondents will have an opportunity to learn about the study at most sites
through tribally-organized informational meetings, radio announcements, newspaper
articles, word of mouth, tribal websites, and advance letters for all sites (See Appendices
L1-4 below). They will receive additional information and clarifications from the
interviewer or through calls they make to project and/or tribal officials.
12
NORC IRB Application for Initial Review
Rev. 8/2012
GAINING COOPERATION: By this time participants should be expecting a call or visit from
the NORC field interviewer. The main purpose of the first call or visit will be to inform the
respondent about the study, answer any questions they may have, be given time to make
an informed decision, and set up an appointment at a time convenient to the respondent.
Interviewers will also accept refusal during this call or visit. The phone script is integrated
into page 1 of the survey instrument in Appendix H. NORC will first work with the tribal
authorities and our tribal liaison to gauge the best and most culturally appropriate gaining
cooperation techniques for sampled respondents.
INFORMED CONSENT AND INTERVIEW: If the respondent agrees, the interview will take
place at the decided time. Any additional questions or concerns may be answered at this
time. Respondent will be read the informed consent statement on page 1 of the
instrument and, after agreeing, the 45 minute interview will begin. At the end of the
interview, locating information will be collected for validation purposes and the interviewer
will thank the respondent for their time and provide the respondent fee or incentive.
USE OF BILINGUAL INTERPRETER: It is a rare possibility that there will be an instance
that a native language interpreter will be needed for gaining cooperation for the interview.
In such cases, we would first look to another household member to fill this role, with the
approval of the respondent. An example of this could occur when the respondent is a
Navajo elder that only speaks the Navajo language. During the outreach phase with the
tribal leaders, this topic will be discussed to estimate if/to what extent language and
proxies will be an issue. Before any interpreter/proxy is used, the Field Manager should
be informed. The Field Manager will discuss the situation with the project management for
approval.
USE OF PROXIES: Proxies may also be requested for elders and those who are unable to
participate but wish for someone else to answer for them. All approvals would go through
the Field Manager and project management first. If no family member is available we will
inquire as to whether there is anyone from the community who could fill this role. When
this happens the respondents will be asked to sign a form (integrated into the informed
consent) giving permission for the proxy to answer the questions of his or her behalf. The
proxy permission is provided on page 3 of Appendix H. We have provided scripts for
informed consent for the Proxy in the survey instrument (who would then receive the
incentive). See Appendix H. (Clarification added 10/23/12)
PRETEST: The gaining cooperation, informed consent, and interview procedures described above
will be conducted for the pretest. Selection of participants will occur at the discretion of the tribe,
as will disclosure about the pretest. We do not anticipate use of bilingual interpreters or proxies
for the pretest.
8.2b
Describe the compensation/incentive for participation (if any) that research subjects will receive and
circumstances under which payment will be prorated.
Survey participants will receive a $25 incentive in the form of gift card or voucher. The decision of
the type of gratuity will be made by tribal officials during the tribal outreach efforts.
Pretest: The same incentive procedure will be followed for the pretest sites.
8.3b
Are subjects chosen from records?
Yes. Specify who gave approval for use of the records: Participants in the survey will be
drawn from the sample used for the Case Record Review. Tribal Leaders will give approval through a
Tribal Resolution or Tribal IRB approval.
No.
13
NORC IRB Application for Initial Review
Rev. 8/2012
8.3.1b If yes, are records “private” medical or student records?
Yes.
Provide the protocol, consent forms, letters, etc. for securing consent of the
subjects of the records. Written documentation for the cooperation/permission
from the holder or custodian of the records should be attached.
No.
9. RISKS AND BENEFITS
9.1
Does the research involve any of these possible risks or harms to subjects?
Check all that apply.
No risks (e.g., secondary analysis of de-identified data) -> Case Record Review only
Annoyance (unwanted attention) -> Participant Survey
Loss of time (perception that the study is not valuable) -> Participant Survey
Intrusive questions or procedures that might be regarded as an invasion of privacy
(right to control access to personal information and person, including biological specimens or
image) -> Participant Survey
Presentation of materials or behaviors regarded as socially unacceptable and might
lead to embarrassment
Moderate physical discomfort
Procedures that may result in mental or emotional stress
Deception (delaying informed consent about the true nature of the study until post-study
debriefing)
Punishment (subjects are denied a benefit for any reason)
Questions about drug use (including caffeine, nicotine, etc.)
Disclosure of information that could lead to severe social stigma or job loss
Disclosure of information that could be legally harmful to subject (e.g., child abuse,
criminal behavior, political repression, or immigration status)
Procedures that may involve physical harm or death to subjects
9.2
What is the level of risk to subjects in this research study?
Not greater than minimal risk (see the note below for definition of minimal risk).
Greater than minimal risk.
NOTE: Studies eligible for Exemption or Expedited Review must involve no more than minimal risk.
Minimal risk is defined by the federal regulations as follows: "the probability and magnitude
of harm or discomfort anticipated in the research are not greater in and of themselves than those
ordinarily encountered in daily life or during the performance of routine physical or psychological
examinations or tests."
10. CONFIDENTIALITY OF DATA
A: Case Record Review
Will you be recording any direct identifiers (e.g., names, social security numbers, addresses, telephone numbers,
etc.)?
Yes. Complete 10.1.1.
No.
14
NORC IRB Application for Initial Review
Rev. 8/2012
10.1.1 Explain why it is necessary to record findings using these identifiers. Describe the coding system
you will use to protect against disclosure of these identifiers.
10.2
Will you retain a link between study code numbers and direct identifiers after the data collection is
complete?
Yes. Complete 10.2.1.
No.
10.2.1 Explain why this is necessary and state how long you will keep this link.
10.3
Will you provide the link or identifier to anyone outside the research team?
Yes. Complete 10.3.1.
No. This is Not Applicable.
10.3.1 Explain why and to whom the link or identifier will be provided outside of the research team.
10.4
Where, how long, and in what format (such as paper, digital or electronic media, video, audio, or
photographic) will data be kept? In addition, describe what security provisions will be taken to protect
this data (password protection, encryption, etc.).
10.5
Are you planning to obtain a Federal Certificate of Confidentiality for this research (or a Privacy
Certificate from NIJ)?
Yes.
No.
B: Participant Survey
10.1
Will you be recording any direct identifiers (e.g., names, social security numbers, addresses, telephone
numbers, etc.)?
Yes. Complete 10.1.1.
No.
10.1.1 Explain why it is necessary to record findings using these identifiers. Describe the coding system
you will use to protect against disclosure of these identifiers.
15
NORC IRB Application for Initial Review
Rev. 8/2012
The names, addresses and phone numbers of individuals who participate in the survey will
be collected but not used in the reporting of data. This information will be used only for
data retrieval and validation (this is a standard operating procedure for surveys). Tribal
leaders and participants will be told the reason for collecting these data and how it will be
destroyed upon survey completion.
Pretest: The respondents will be a convenience sample from the list of participants
provided by the Food Distribution Program on each of the two reservations. We will not be
collecting any additional identifying information from the pretest respondents.
10.2
Will you retain a link between study code numbers and direct identifiers after the data collection is
complete?
Yes. Complete 10.2.1.
No.
10.2.1 Explain why this is necessary and state how long you will keep this link.
10.3
Will you provide the link or identifier to anyone outside the research team?
Yes. Complete 10.3.1.
No. This is Not Applicable.
10.3.1 Explain why and to whom the link or identifier will be provided outside of the research team.
10.4
Where, how long, and in what format (such as paper, digital or electronic media, video, audio, or
photographic) will data be kept? In addition, describe what security provisions will be taken to protect
this data (password protection, encryption, etc.).
Survey data will be kept until completion of the study in September 2014.
Protection of respondent confidentiality and PAPI questionnaires: Field Interviewers and Field
Managers will observe NORC policies and procedures for data security. Upon completion of the
Participant Survey, Field Interviewers and Field Managers (respectively) will secure the physical
copies of the PAPI questionnaires in a locked file or cabinet that is accessible only to them. Field
Interviewers and Mangers will ship completed questionnaires via a secure and traceable carrier to
NORC’s receipt control center on a weekly basis. Upon control and receipt, the cover page,
informed consent, and validation information will be separated from the questionnaire. Each
completed interview will be assigned an identifier that does not contain personally-identifiable
information.
All interviewers will sign NORC’s Pledge of Confidentiality prior to data collection.
Pretest: The respondents will be a convenience sample from the list of participants provided by
the Food Distribution Program on each of the two reservations. We will not be collecting any
additional identifying information from the pretest respondents. With the subject’s permission, we
do plan to audio-tape pretest interviews to hear how the question working works and what
questions the subjects have a difficult time understanding. The Informed Consent form for the
pretest of the Participant Survey also includes a request for permission to audio-tape (see
Appendix H). The audio tapes will be destroyed when OMB clearance has been received, which is
16
NORC IRB Application for Initial Review
Rev. 8/2012
estimated to be July 2013.
10.5
Are you planning to obtain a Federal Certificate of Confidentiality for this research (or a Privacy
Certificate from NIJ)?
Yes.
No.
NOTE: A “Certificate of Confidentiality” helps researchers protect the privacy of human research
participants enrolled in sensitive research. A Certificate of Confidentiality protects against
compulsory legal demands, such as court orders and subpoenas, for identifying information or
identifying characteristics of a research participant. Sensitive information includes (but is not
limited to) information relating to sexual attitudes, preferences, or practices; information
relating to the use of alcohol, drugs, or other addictive products; information pertaining to
illegal conduct; information that, if released, might be damaging to an individual's financial
standing, employability, or reputation within the community or might lead to social
stigmatization or discrimination; information pertaining to an individual's psychological wellbeing or mental health; and genetic information or tissue samples.
For research funded by the National Institute of Justice, a Privacy Certificate is required rather
than a Certificate of Confidentiality—see the NIJ website for further guidance on obtaining a
Privacy Certificate.
11. USE OF PROTECTED HEALTH INFORMATION (PHI): HIPAA COMPLIANCE
11.1
Read the following definition of PHI to ensure your responses to 11.2 and 11.3 are correct:
PHI is defined under HIPAA as health information transmitted or maintained in any form or medium that:
1.
Identifies or could be used to identify an individual;
2.
Is created or received by a healthcare provider, health plan, employer or healthcare clearinghouse; and
3.
Relates to the past, present or future physical or mental health or condition of an individual; the provision of
health care to an individual; or the past, present or future payment for the provision of healthcare to an
individual.
Health-related information is considered PHI if (any of the following are true):
a.
The researcher obtains it directly from a provider, health plan, health clearinghouse or
employer(other than records relating solely to employment status);
b.
The records were created by any of the entities in "1" and the researcher obtains the records from an
intermediate source which is NOT a school record or an employer record related solely to employment
status; or
c.
The researcher obtains it directly from the study subject in the course of providing treatment to the
subject.
Health-related information is not considered PHI if the researcher obtains it from:
a.
Student records maintained by a school (in which case, FERPA would apply); or
b.
Employee records maintained by an employer related to employment status.
However, existing IRB rules on informed consent and confidentiality still apply.
17
NORC IRB Application for Initial Review
11.2
Rev. 8/2012
As part of this study, do you plan to collect PHI from research subjects and/or have access to PHI in
research subjects’ records?
Yes. Complete Appendix E to show how the project plans to comply with HIPAA’s requirements
pertaining to PHI.
No. This response applies to both the Case Record Review and the Participant Survey.
12. RESEARCH THAT INVOLVES STUDENTS/SCHOOL RECORDS
12.1 As part of this research, do you plan to access student education records or undertake
surveys, examination, testing, or treatment of students in elementary and/or secondary schools?
Yes.
No. If you answered No, skip the remaining questions in this Section, and go to Section 13.
This response applies to both the Case Record Review and the Participant Survey
12.1
As part of this research, do you plan to access student education records?
Yes. FERPA may apply to your research. See the note below.
No.
NOTE: If you answered Yes to Question 12.1, the Family Educational Rights and Privacy Act (FERPA) may
apply to your research. See the NORC IRB’s Guidance on FERPA on the IRB webpage. Guidance on
FERPA is also available on the U.S. Department of Education website at
http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html.
12.2
Will your research involve surveys or psychiatric/psychological examination, testing, or treatment of
students in elementary and/or secondary schools?
Yes.
No.
If you answered Yes, you need to be aware of the Protection of Pupil Rights Amendment (PPRA).
Under the PPRA, parental consent and minor assent is required and may not be waived for studies
involving surveys, psychiatric examination, testing, or treatment, or psychological examination, testing,
or treatment, in which the primary purpose is to reveal information concerning one or more of the
following:
a. Political affiliations
b. Mental and psychological problems potentially embarrassing to the student or his or her family
c. Sex behavior and attitudes
d. Illegal, anti-social, self-incriminating and demeaning behavior
e. Critical appraisals of other individuals with whom the student has close family relationships
f. Legally recognized privileged & analogous relationships, such as those of lawyers, physicians &
ministers
g. Religious practices, affiliations, or beliefs of the student or student’s parent
h. Income, other than that required by law to determine eligibility for participation in a program or for
receiving financial assistance under a program
The IRB does not have the authority to issue a waiver of informed consent on any of the areas of inquiry
set forth in PPRA or to overrule school district policies for implementing PPRA.
For more information on the PPRA, see the NORC IRB’s guidance on the IRB webpage, and the
guidance on the U.S. Department of Education website at
http://www2.ed.gov/policy/gen/guid/fpco/ppra/index.html.
18
NORC IRB Application for Initial Review
Rev. 8/2012
13. INFORMED CONSENT PROCESS
A: Case Record Review
13.1a In relation to the actual data gathering, when and how will consent be discussed and documented
(e.g., mailing out materials, delivery of consent form, meetings)? Be specific.
Federal Officials and Tribal Leaders will participate in five government-to-government
Consultations between November 2012-January 2013. Tribal leaders will provide consent for the
drawing of the sample for the case record review. Four advance letters will be sent:
1)
2)
3)
4)
from
from
from
from
USDA/FNS to tribal leaders
the Urban Institute/NORC to tribal leaders
USDA/FNS to FDPIR directors
the Urban Institute/NORC to FDPIR Directors
The letters are provided in Appendices L1-4.
13.2a Explain which individuals will obtain informed consent.
Informed consent for the case record review will not be obtained from individuals but from the
Tribal leaders or Tribal Council through a tribal resolution. This document will serve as data
sharing agreement with NORC to conduct the case record review. This is likely to be the
tribe/ITO’s preferred mode for engaging in collaborative relationship to conduct the case record
review, as such it is culturally competent approach to establishing community-level consent
through tribal governance, along with community disclosure procedures. The general terms of
resolution will be discussed during the Consultations with the tribes/ITOs. As tribes are unique
and have different mechanisms and procedures research review, it is likely that the draft language
in the resolution will be revised during our outreach effort. A sample tribal resolution is provided
in Appendix M.
13.3a How will you determine who will give consent? That is, will the subject, parent, guardian, or Legally
Authorized Representative be asked to consent to the subjects’ participation in this study?
The appropriate protocol is for tribal leaders and/or the tribe’s research review body to consent to
participation in the study. However, not all tribes have IRBs or research review bodies in place.
NOTE: If research subjects are minors, it is necessary to complete Appendix C—Research that Involves
Children to provide the IRB with more complete information about how you plan to conduct the
consent and assent process.
13.5b Will the project request a Waiver/Alteration of Consent or Waiver of Documentation of Consent?
No.
Yes.
Complete and submit Appendix A–Waiver of Documentation of Consent and/or Appendix
B–Waiver or Alteration of Informed Consent.
We are requesting a Waiver/Alteration of Consent for the Case Record Review as this
component of the study meets the criteria as specified: “Collection of data from records
where the investigator will not directly interact with the participants.” Appendix B is
attached.
NOTE: Under specific conditions, informed consent, or documentation of signed informed consent, can be
waived or altered. These limited conditions are described in 45 CFR 46.116 and 45 CFR 46.117.
19
NORC IRB Application for Initial Review
Rev. 8/2012
B: Participant Survey
13.1a In relation to the actual data gathering, when and how will consent be discussed and documented
(e.g., mailing out materials, delivery of consent form, meetings)? Be specific.
Subjects will receive an advance letter and brochure. During the informed consent process,
participants will be informed about the study purpose, risks, and potential benefits. Informed consent
will be obtained at the beginning of the interview. We anticipate that each tribe/ITO will require
slight changes in wording to the informed consent language to increase cultural sensitivity.
13.2b Explain which individuals will obtain informed consent.
NORC-trained field interviewers will obtain informed consent.
Field Manager and Interviewer training will include a module on Human Subject Protections and
protecting respondent confidentiality. We will incorporate any tribal guidance about obtaining
informed consent into our training process.
It is possible that a participant may decline to participate in the interview himself/herself for
cultural reasons and wish to have another person (i.e., a Proxy) speak on his/her behalf. To this
end, we have provided scripts for informed consent for the Proxy (who would then receive the
incentive). See Appendix H. (Clarification added 10/23/12)
13.3c How will you determine who will give consent? That is, will the subject, parent, guardian, or Legally
Authorized Representative be asked to consent to the subjects’ participation in this study?
Only the interview participant will provide informed consent.
In the scenario described above, if a participant wish another person to speak on his/her behalf
and designates a Proxy, then we will consent the Proxy. A script is provided in Appendix H.
NOTE: If research subjects are minors, it is necessary to complete Appendix C—Research that Involves
Children to provide the IRB with more complete information about how you plan to conduct the
consent and assent process.
13.5d Will the project request a Waiver/Alteration of Consent or Waiver of Documentation of Consent?
No.
Yes.
Complete and submit Appendix A–Waiver of Documentation of Consent and/or Appendix
B–Waiver or Alteration of Informed Consent.
We are requesting a Waiver of Documentation of Consent for the Participant Survey.
Appendix A is attached.
We are requesting a Waiver/Alteration of Consent for the Participant Survey as this
component of the study meets the criteria as specified: “Potential participants will be
identified and then contacted about participation in the research based upon existing
records” (i.e., the Household Issuance Inventory list provided by each tribe/ITO). “The
human subject research activities begin when clinical or other records are accessed in
order to obtain contact information and/or screen participants for inclusion in the research.
Because written consent cannot be obtained from the participants to allow access and use
of those records for recruitment purposes, a waiver of consent is needed.” Appendix B is
attached.
NOTE: Under specific conditions, informed consent, or documentation of signed informed consent, can be
waived or altered. These limited conditions are described in 45 CFR 46.116 and 45 CFR 46.117.
20
NORC IRB Application for Initial Review
Rev. 8/2012
14. IRB APPENDICES CHECK LIST
14.1
Check all the IRB appendices that apply to your project. Be sure to include them with your submission.
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
A – Waiver of Documentation of Consent. For the Participant Survey
B – Waiver or Alteration of Informed Consent. For the Case Record Review
C – Research that Involves Children.
D – Prisoner Research.
E – HIPAA Compliance. For the Case Record Review Not Applicable 10/12/12
F – International Research.
15. INVESTIGATOR ASSURANCE
15.1
Read the investigator assurance statement below, and sign to indicate your acceptance. A signature is
required from the Principal Investigator or the Project Director. The signature may be typed in if the protocol is
submitted electronically from the email account of the Principal Investigator, the Project Director, or an authorized
member of the project team; otherwise, please send a signed hard copy of this page to the IRB office.
The information provided in this form is correct. I have evaluated this protocol and determined that I
have the resources necessary to protect participants, such as adequate funding, appropriately
trained staff, and necessary facilities and equipment. I will seek and obtain prior written approval
from the IRB for any substantive modifications in the proposal, including changes in procedures, coinvestigators, funding agencies, etc. I will promptly report any unexpected or otherwise significant
adverse events or unanticipated problems or incidents that may occur in the course of this study. I
will report in writing any significant new findings which develop during the course of this study which
may affect the risks and benefits to participation. I will not begin my research until I have received
written notification of final IRB approval. I will comply with all IRB requests to report on the status of
the study. I will maintain records of this research according to IRB guidelines. The grant that I have
submitted to my funding agency which is submitted with this IRB submission accurately and
completely reflects what is contained in this application. If these conditions are not met, I
understand that approval of this research could be suspended or terminated.
Principal Investigator:
Project Director:
Date:
CAROL HAFFORD
Date: 10/10/12
Protocol amended 10/23/12
21
NORC IRB Appendix A—Waiver of Documentation of Informed Consent
Rev. 6/2012
NORC IRB APPENDIX A—
Request For Waiver Of Documentation Of Informed Consent
Project Number:
Project Title:
6954
Study of the Food Distribution Program
On Indian Reservations
Background: Federal Regulations
The HHS regulations discuss the requirements to document the consent process by using a
written document and obtaining a signature as a separate event from providing the
elements of consent to the participant (the consent process), because it is possible to have
a consent process occur without obtaining a written signature from participants or giving
them a written document.
When to request a waiver of documentation of consent:
Example 1: If the research involves telephone interviews or on-line surveys, it may be
appropriate to complete the consent process verbally or on-line and not obtain a written
signature from the participant. In these instances, a waiver of documentation may be
granted when the research involves minimal risk and the proposed research methods and
procedures usually do not require written consent when used outside of a research
context. For example, many surveys (written or telephone) are completed by people for
various reasons and normally people are not required to sign a consent to complete a
survey.
Example 2: For some research protocols, the greatest risk to the participant may be a
breach of confidentiality and having their name associated with the research and the
research data, so a waiver of documentation is appropriate as a measure of protection
against this risk. This is commonly seen in research involving illegal behaviors, information
or data that is stigmatizing to reputation, or that involves a risk to employability or
insurability. This waiver of documentation is also recommended when the signed consent
form would be the only document that contains the identification of the participant, the
greatest risk to the participant is being linked to the data or the research study, and there is
no need to document the participant’s name in the research records.
1
NORC IRB Appendix A—Waiver of Documentation of Informed Consent
Rev. 6/2012
Differences between waiver of documentation and waiver of consent
A waiver of documentation of consent is not a waiver of the consent process – it is a
waiver of the requirement to obtain a signature from the participant. When the requirement
to obtain a signature is waived, the researcher must still obtain consent, usually either
verbally or on-line, and whenever possible the investigator should have the verbal consent
discussion with the participant, and should provide a copy of the consent text to the
participant. A waiver of documentation can also be applied to the parental permission or
assent process, if it is appropriate.
Waiver or Alteration of Consent: If other aspects of the consent process are not
possible due to the research design, a waiver or an alteration of consent should also be
requested using Appendix B (Waiver & Alteration of Informed Consent). For example, an
alteration of consent might involve not having a verbal discussion with the parents and
sending the parental permission home for signature, or not including the true purpose of the
research in the initial consent process if the study involves deception. A waiver of consent
might also be used in instances where no actual contact with the participants will occur and
the data collected on human subjects is from identifiable records.
How to Request a Waiver of Documentation: The regulations allow for a
waiver of documentation of consent based on two criteria. If you wish to request a waiver of
the requirement to obtain a signed consent form for some or all subjects [45 CFR
46.117(c)], check the category that would apply to your research and provide the rationale
for the waiver:
1. Choose which waiver criteria apply to your research. If requesting a waiver of
documentation, at least one yes box must be checked. Depending upon the
complexity of your research, it is possible that both criteria may apply to differing
aspects of your research.
a) The only record linking the subject and the research is the consent
document, and the principal risk is potential harm resulting from a breach
of confidentiality. When appropriate, subjects are asked whether they
want documentation linking them to the research, and their wishes will
govern.
Yes
No
This pertains to the Participant Survey.
Additional information:
In cases when the documentation requirement is waived, the IRB may require
the investigator to provide subjects with a written statement regarding the
research (i.e. a consent script or handout). However, depending upon the
research, participants do not necessarily retain any documents related to the
research to which they have consented. For some research, in order to allow
for the participant to ask questions, report concerns and unanticipated
problems, it is recommended that at a minimum the PI provide the participant
with contact information. However, the participant may wish to retain a copy
2
NORC IRB Appendix A—Waiver of Documentation of Informed Consent
Rev. 6/2012
of the approved informed consent document, even if he/she does not formally
sign it.
The PI and/or research staff should document that the participant provided
consent, along with the date, potentially the time, and the name of the
person conducting the consent process in the study files. The documentation
process should not include the name of the participant or any direct
identifiers, but can include a coded identifier for the individual.
Waiver of documentation need not apply to each and every participant in the
study. In most cases, the waiver of documentation has been granted by the
IRB for reasons related to decreasing the research-related risks, but some
participants may wish to sign and retain a copy of the informed consent
document. They should be given the choice of doing so.
b) The research involves no more than minimal risk of harm and involves no
procedure for which written consent is normally required outside of the
research context.
Yes
No
This pertains to the Participant Survey.
*Minimal risk is defined as: The probability and magnitude of physical or psychological harm or
discomfort anticipated in the research are not greater in and of themselves than those ordinarily
encountered in daily life or during the performance of routine physical or psychological
examinations or tests.
Additional Information:
On-line surveys or telephone interviews are frequently completed by people for
many reasons outside of human subject research and most of the time completing
the survey or interview implies consent. It is only because the survey or interview
activity is human subjects research that we think about obtaining a signature. So as
long as the research is limited to a survey or interview procedure where a written
consent would not usually be obtained if this were not human subjects research,
this option is appropriate.
2. Please describe the reasons why the waiver of documentation of consent is
necessary for your research.
We understand informed consent will be an ongoing process and in that spirit have developed steps
we believe will cover all required elements of informed consent.
First, the advance letters proved a great deal of information about the study. The letters provide three
means of contacting the project – Principal Investigator and Project Director contact information, a
project email address, and a toll-free number (Appendices L2 and L3). In addition, the letters
provide information about the purpose of the study and who is funding it. Also provided in the letters
is a description of the survey procedure, expected duration of the interview, respondent incentive, and
voluntary nature of participation. Confidentiality and privacy are also covered. All respondents will
receive a copy of the advance letter and the field interviewers will have ample copies to distribute.
A project brochure has been developed to reinforce the information in the letter and to tell the
prospective respondents more about the project (Appendix K). The project brochure also includes
additional information about the Urban Institute and NORC and contact information, including
3
NORC IRB Appendix A—Waiver of Documentation of Informed Consent
Rev. 6/2012
websites, for both organizations. Also included in the brochure are questions and answers to probable
questions the community or respondents may have. A generic NORC brochure will also be included
the advance package (not attached).
Verbal informed consent will be sought in person prior to conducting the interview. The consent script
will be read to each respondent at the beginning of the survey instrument. The script reiterates the
reason for the survey, the voluntary nature of the survey, confidentiality, survey topics, how the
information will help the community, and privacy. The IRB Human Subjects toll-free number is also
included, along with an email address.
Before starting the interview, the respondent is asked if they are ready to start. Upon their assent,
the interviewer will proceed with the body of the questionnaire. Interviewers will, of course, be able
to answer any questions prior to starting the interview, and all respondents will have received the
advance letters and brochures.
4
NORC IRB Appendix B – Waiver or Alteration of Informed Consent
Rev. 5/2012
NORC IRB APPENDIX B—
Request for Waiver or Alteration of Informed Consent
Project Number: 6954
Project Title:
Study of the Food Distribution Program on Indian Reservations
If your research involves minors and you are seeking a waiver of parental permission or
a waiver of assent, please complete Appendix C instead – Research that Involves
Children
The IRB will not grant a waiver of informed consent for research that involves accessing
certain information contained in student educational records, due to provisions
contained in the Family Educational Rights and Privacy Act (FERPA). See the IRB
webpage on the intranet for more information on FERPA.
The IRB will not grant waivers of informed consent for surveys, psychiatric examination,
testing, or treatment, or psychological examination, testing, or treatment in which the
primary purpose is to reveal information concerning one or more of the eight protected
areas (“protected information surveys”) specified in the Protection of Pupil Rights
Amendment (PPRA). See the IRB webpage on the intranet for more information on
PPRA.
Background: Federal Regulations: The federal regulations [45 CFR 46.116] list 8 required
elements or statements that must be in a consent document/process and 6 additional elements
that must be present when they are applicable to the research protocol. The IRB may waive or
alter all or some of the elements of consent or the consent process, as necessary for the research.
A waiver or alteration of consent may also be applied to parent/guardian permission and assent
under 45 CFR 46.116(d), and under Subpart D of 45 CFR 46.408 (c) and 45 CFR 46.408(a).
Waivers of Consent:
Definition: When the consent process is waived in its entirety that means all elements of the
consent process are waived, so there is no form or information provided to the participant and no
verbal review of the research with the participant.
Examples: Waivers of consent are frequently used in research that involves collection of data from
records where the investigator will not directly interact with the participants, observational studies,
or when potential participants will be identified and then contacted about participation in the
research based upon existing records, such as clinical or archival records. In the latter case, the
human subject research activities begin when clinical or other records are accessed in order to
obtain contact information and/or screen participants for inclusion in the research. Because written
consent cannot be obtained from the participants to allow access and use of those records for
recruitment purposes, a waiver of consent is needed.
1
NORC IRB Appendix B – Waiver or Alteration of Informed Consent
Rev. 5/2012
Alterations of Consent:
Definition: An alteration of consent involves a change in one or more of the elements of consent
or the consent process.
Examples:
When deception is used in the research. Deception involves not disclosing the true purpose
and/or methods to the participants before the research is conducted at the time of the
original consent process. When deception is used, the participants should be debriefed after
the completion of the research and told the true information about the research.
When parent/guardian permission forms are sent home to parents and returned to the
investigator without a verbal discussion, questions being addressed, and an evaluation of
understanding.
Requesting a Waiver or alteration of consent: In order for the IRB to grant a waiver or
alteration of consent, all four regulatory criteria noted below must be met. If you wish to request
(a) a waiver of informed consent [45 CFR 46.116(d)] or (b) an alteration of consent or consent
process [45 CFR 46.116(d)], you should review the four criteria below and indicate that the
requirements are met for your research.
NOTE: This request applies to the Case Record Review and the Participant Survey.
Indicate One
Yes
The research in its entirety involves no greater than minimal risk.
No
The waiver/alteration of informed consent will not adversely affect the rights and
welfare of the subjects.
Yes
No
It is not practicable to conduct the research without the waiver/alteration (Neither
lack of adequate funds nor inconvenience are acceptable justifications for
impracticability.)
Yes
No
Whenever appropriate, subjects will be provided with additional pertinent information
after their participation. (i.e. debriefing, when deception is involved)
Yes
No
NOTE: If you checked “no” for any of these criteria, then you do not meet the
requirements for a waiver or alteration of consent and should stop completing this form.
2
FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS: CASE RECORD REVIEW FORM
[NAME]
TRIBE/ITO
RELATIONSHIP TO
FDPIR APPLICANT
[ITO #-001]
FDPIR IDENTIFIER
CASE NUMBER (system generated from AIS)
FDPIR PARTICIPANT
FOOD STAMPS
AGE
Receiving?
Y/N
Applied for?
Y/N
[#]
HOUSEHOLD SIZE
OMB CONTROL NUMBER: xxxxxxx
[NEW/RECERTIFIED]
CERTIFICATION STATUS
INCOME (EARNED AND UNEARNED)
Disqualified?
Source 1:
Income
Type
Amount
Enter $
amount
Y/N
Source 2:
Income
Type
Amount
Source 3:
Income
Type
Enter $
amount
Amount
Enter $
amount
Source 4:
Income
Type
Amount
Enter $
amount
1 self
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Relationship to FDPIR Applicant
Spouse
Partner
Son
Daughter
Step-child
Foster-child
Mother
Step-mother
Father
Step-father
Brother
Sister
Grandmother
Grandfather
Aunt
Uncle
Cousin
Niece
Nephew
Mother-in-law
Father-in-law
Sister-in-law
Brother-in-law
Other-in-law
Roomer/boarder
Other non-relative
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
Income
Social Security
SSI
TANF
General/Public Assistance
Foster Care Payments
Unemployment Insurance
Worker's Compensation
Child Support
Alimony
Pensions
Veteran's Benefits
Per capita payments
Work/training allowances
Other:
No income source
Quality Control review conducted by: [NAME], [MM/DD/YYYY]
Case Record Review data abstraction done by [NAME]
Abstraction date: [MM/DD/YYY]
[Page X of Y]
FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS: CASE RECORD REVIEW FORM
SELF-EMPLOYMENT INCOME
Household
Type of
Member SelfBusiness
Employed
Occupation
Y/N
STUDENTS
Primary Source
of Income?
Y/N/NA
Student
Amount of
Receiving
Loan/Grant
Financial Aid?
Y/N
Time
Period
Enter $
amount
OMB CONTROL NUMBER: xxxxxxx
RESOURCES
Type of
Payment
Amount
Used for
Tuition/Fees
Cash on
Hand
Checking/
Savings
Account
Stock/Bonds/
CDs/Other
Enter $
amount
Enter $
amount
Enter $
amount
Enter $
amount
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
Y/N/NA
A
B
C
D
E
F
G
Self-Employment Income
Rental Property
Roomers
Boarders
Farming
Ranching
A
B
C
D
E
Type of Student Aid
Pell Grant
Student Loan
BIA
Scholarship
Other:
Own business
Other:
Quality Control review conducted by: [NAME], [MM/DD/YYYY]
Case Record Review data abstraction done by [NAME]
Abstraction date: [MM/DD/YYY]
[Page X of Y]
FDPIR Survey updated 9/10/11
INTERVIEWER: BEFORE STARTING INTERVIEW PLEASE ENTER AVAILABLE AIS DATA IN QUESTION E1.
FDPIR Participant Survey
INTERVIEWER READ: “Hello, my name is [name of interviewer] from NORC at the University of
Chicago. [IF IN PERSON - SHOW NORC ID CARD.] I am (calling/here) about the Study of the Food
Distribution Program on Indian Reservations. Have you by any chance received our letter? It tells
about the study and also mentions you will receive (cash/gift card).
IF YES: Do you have any questions about the survey? May I tell you more about the survey?
IF NO: IN PERSON: Here is a copy of the letter and some information about the project. Should I
leave the materials and come back or call at a later time or could I answer any questions you may
have at this time?
IF NO: TELEPHONE: I can read the letter to you and also send you another copy and some additional
materials in the mail.
INFORMED CONSENT [For PRE-TEST only]
We are conducting a pre-test of the survey for use in a national study of the Food Distribution
Program on Indian Reservations. This survey is being done to help understand the food needs of
American Indian and Alaska Native families. It is sponsored by the U.S. Department of Agriculture,
Food and Nutrition Service.
We are doing this pre-test to see how well the questions are worded and whether people like you that
would be taking the survey have a hard time understanding any of the survey questions. The survey
will ask you about the members of your household, (FDPIR/name of program) contribution to your
food supply, the distribution and delivery of the FDPIR food packages, your food access and costs, any
nutrition and health related services available, switching between SNAP and FDPIR and your
satisfaction with the FDPIR program.
Taking this pre-test survey is voluntary, which means that you don’t have to take the survey if you
don’t want to. Also, you can decide not to answer any specific questions. You also may end the
interview at any point. You will receive a [CASH GIFT/ GIFT CARD/VOUCHER] as a thank you for
taking the survey. The interview will take about 45 minutes.
The information you provide will be confidential, and will not be shared with anyone except for
research staff working on the study. This includes anything that can identify you such as your name,
address, or telephone number. Everyone who works on this survey has signed a legal document
stating they will not reveal any of your personal information and can be severely penalized if they do.
We will not use the actual data from the pre-test in any reports to the federal government and the
information we collect from you will be destroyed in July 2013.
1
FDPIR Survey updated 9/10/11
INFORMED CONSENT [FOR MAIN FIELDING]
As you may have learned from the [ADVANCE LETTER SENT/MATERIALS SHARED/TRIBAL
LETTER/COMMUNITY PRESENTATION HELD], this survey is being done to help understand the food
needs of American Indian and Alaska Native families. It is sponsored by the Department of
Agriculture, Food and Nutrition Service.
Your participation is very important to the success of this survey. This survey is voluntary, which
means that you don’t have to take the survey if you don’t want to, and you can decide not to answer
any specific questions. You also may end the interview at any point. You will receive a [CASH GIFT/
GIFT CARD/VOUCHER] as a thank you for taking the survey. The interview will take about 45
minutes.
The information you provide will be confidential, and will not be shared with anyone except for
research staff working on the study. This includes anything that can identify you such as your name,
address, or telephone number. Everyone who works on this survey has signed a legal document
stating they will not reveal any of your personal information and can be severely penalized if they do.
A report will be shared with the tribe/native village at a later date. It will summarize the findings,
without giving names or other information that would identify you or the tribe/native village.
The survey will ask you about the members of your household, (FDPIR/name of program)
contribution to your food supply, the distribution and delivery of the FDPIR food packages, your food
access and costs, any nutrition and health related services available, switching between SNAP and
FDPIR and your satisfaction with the FDPIR program.
The information you provide will be helpful to improve food services in your community and other
communities in Indian Country.
If you have questions about your rights as a survey participant, please call the IRB Human Subjects
Protection hotline, toll-free, at (866) 309-0542. You may also email [insert name here]@norc.org or
visit www.norc.org.
USE OF AUDIO-TAPE (FOR PRETEST ONLY)
It would be helpful to audio-tape the pretest interviews. It will help us hear how the question
wording works and what questions participants have a difficult time understanding. The audio tape
will be destroyed by July 2013.
Do I have your permission to record the interview?
IF YES, Let’s begin.
IF NO, That’s fine. Let’s begin without it.
2
FDPIR Survey updated 9/10/11
INFORMED CONSENT FOR USE OF PROXY [For PRE-TEST or MAIN FIELDING]
Step 1. If respondent declines to participate in the interview but requests that another person responds
to the questions on his/her behalf: 1
For in-person interview:
I have chosen not to participate in the interview but would like [name of person] to answer the
survey questions for me.
Request signature if the interview is conducted in person:
Respondent Name: _____________________________________________________________
Signature: __________________________________________________________
For telephone interview:
You stated that “I have chosen not to participate in the interview but would like [name of person] to
answer the survey questions for me.” Is this correct?
IF YES, I will note your agreement and obtain informed consent from [name of person].
Respondent Name: _____________________________________________________________
IF NO, Thank you for your time. [Terminate interview.]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Step 2. To consent the person who will respond on the respondents’ behalf:
[Name of respondent’s] has declined to participate in the interview and requests that you answer
questions about [his/her]FDPIR participation. Would you be able to answer questions on his/her
behalf?
IF YES, I will need to request your informed consent to answer the survey questions.
IF NO, Thank you for your time. [Terminate interview.]
As you may have learned from the [ADVANCE LETTER SENT/MATERIALS SHARED/TRIBAL
LETTER/COMMUNITY PRESENTATION HELD], this survey is conducted to help understand the food
We anticipate that there will be instances where an elder wishes that another person (e.g., adult child,
grandchild) speaks on his/her behalf about participation in the program.
1
3
FDPIR Survey updated 9/10/11
needs of American Indian and Alaska Native families. It is sponsored by the Department of
Agriculture, Food and Nutrition Service.
Your participation is very important to the success of this survey. This survey is voluntary, which
means that you don’t have to participate and you can decide not to answer any specific questions.
You also may end the interview at any point. You will receive a [CASH GIFT/ GIFT CARD/VOUCHER]
as a token of appreciation for participating in the survey. The interview will take about 45 minutes.
The information you provide will be confidential, and will not be shared with anyone except for
research staff working on the study. This includes anything that can identify you such as the
[respondent’s] name, address, or telephone number. Everyone who works on this survey has signed a
legal document stating they will not reveal any of his/her personal information and can be severely
penalized if they do. A report will be shared with the tribe/native village at a later date. It will
summarize the findings, without giving names or other information that would identify him/her or
the tribe/native village.
The survey will ask about the members of [his/her] household, (FDPIR/name of program)
contribution to [his/her] food supply, the distribution and delivery of the FDPIR food packages,
[his/her] food access and costs, any nutrition and health related services available, switching
between SNAP and FDPIR and [his/her] satisfaction with the FDPIR program.
The information you provide on [respondent’s name behalf] will be helpful to improve food services
in [his/her] community and other communities in Indian Country.
If you have questions about your rights as a survey participant, please call the IRB Human Subjects
Protection hotline, toll-free, at (866) 309-0542. You may also email @norc.org or visit www.norc.org.
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
4
FDPIR Survey updated 9/10/11
USE OF PROXY (FOR MAIN FIELDING)
(Name of Respondent) has given permission for you to act as a proxy for him/her and answer
questions for the Food Distribution Program on Indian Reservations. The interview will take
approximately 45 minutes). Remember you are answering the questions for (name of respondent)
and not as you would answer them for yourself. I will remind you of that again during the
interview. Do you have any questions? Is now a good time to start?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
5
FDPIR Survey updated 9/10/11
PERMISSION TO BEGIN INTERVIEW (FOR PRETEST AND MAIN FIELDING)
Do I have your permission to begin the interview?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time informed consent obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Informed consent obtained by ___________________________________________
Name of Field Interviewer
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to come back?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
What is the reason you prefer not doing the interview?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6
FDPIR Survey updated 9/10/11
USE OF Translator? (FOR MAIN FIELDING)
(Name of Respondent) has given permission for you to act as a proxy for him/her and answer
questions for the Food Distribution Program on Indian Reservations. The interview will take
approximately 45 minutes). Remember you are answering the questions for (name of respondent)
and not as you would answer them for yourself. I will remind you of that again during the
interview. Do you have any questions? Is now a good time to start?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
7
FDPIR Survey updated 9/10/11
Time began: __:____
HOUSEHOLD ENUMERATION
INTERVIEWERS: COMPLETE THE HOUSEHOLD ROSTER ON THE NEXT PAGE BY ASKING EACH OF THE QUESTIONS LISTED BELOW FOR
EACH SECTION.
1
Please tell me the names of all persons who live in your household starting with you – the FDPIR applicant. Just tell me their first names. Let’s start with you.
…Do you have a spouse living in the household?
...any children?
…any grandchildren?
…any relatives?
…anyone that is not related to you?
…anyone else that you have not mentioned?
I have listed…(read names from grid)…Have I missed…any babies or small children?
…anyone who usually lives with you but is away now traveling, at school, or in the hospital?
…any lodgers, boarders, or persons you employ who live with you?
…anyone who is part of the household but is away on full-time active duty with the Armed Forces?
…anyone else staying with you?
2
3
4
5
6
7
8
9
10
11
IF RESPONDENT SAYS ‘YES’ TO ANY OF THE CATEGORIES ADD THAT PERSON(S) TO THE LIST ON THE GRID.
Now we would like to ask how each person is related to you. Let’s start with (name of first person), how is he/she related to you?
ASK OR VERIFY GENDER OF EACH PERSON LISTED.
How old were (you/person) on your/his/her last birthday?
FOR EACH PERSON 18 YEARS AND OLDER ASK: What is (your/person’s) marital status. Is he/she married, never married, separated, widowed or divorced?
FOR EACH PERSON ASK: What is the highest year of education (you/person) has completed?
FOR EACH PERSON ASK: Are you/person currently a student?
FOR EACH PERSON OVER 18: Are you/person currently employed? IF YES: Are you/person (READ CATEGORIES ON CHART) CODE EMPLOYMENT STATUS FOR EACH
PERSON. IF WORKING: How many hours per week do you/does person work?
Does anyone in the household receive Social Security, SSI, LIHEAP, TANF or unemployment benefits? IF YES: Who and what do they receive?
Does anyone in the household have access to the internet? IF YES: Who?
Does anyone in the household own or lease a vehicle? IF YES: Who
8
FDPIR Survey updated 9/10/11
HOUSEHOLD ENUMERATION
STATUS
8.
EMPLOYMENT
STATUS
Student ENTER Yes/√
8a.
Hours
per
Week
9.
Other
Benefits
11.
OWN/LEASE
VEHICLE
MARITAL
7..
10.
IINTERNET
ACCESS
5.
6.
EDUCATION
4. AGE
3. GENDER
NAMES OF HOUSEHOLD
MEMBERS
2. REL TO
APPLICANT
Person #
1.
YES/√
YES/√
SELF
01
02
03
04
05
06
07
08
09
10
11
12
a. Spouse
B. Partner
c. Son/Daughter
d. Step-child
e. Foster child
f. Mother
g. Step mother
h. Foster mother
i. Father
j. Step-father
k. Foster father
l. Brother/sister
m. Grandparent
n. Uncle/aunt
o. Cousin
p. Nephew/niece
q. Father-in-law
r. Mother-in-law
s. Bro/sis-in-law
t. Other-in-law
u. Other non-relative
Married (M)
Never married (NM)
Separated (S)
Divorced (D)
Widowed (W)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Less than high school
Some high school, no diploma
High school diploma
Technical school
Trade apprentice
Some college, no diploma
Collage degree
Graduate or professional studies after
collage
Graduate degree
Don’t know
9. Refused
a.
b.
c.
d.
e.
Not working
Working full time
Working part time
In school
Cannot work –
disabled
f.
Job training
g.
TANF approved work
activity
h. Something else
(SPECIFY)
a. SS
b. LIHEAP
c. TANF
d. Unemp.
e. SSI
9
FDPIR Survey updated 9/10/11
Section A: Participant and Household Characteristics
The first section of the interview will help us better understand the characteristics of FDPIR participants and their
households. We’ll begin by talking about where you live, what kind of resources you have in your home for
preparing and storing food and who prepares food.
A1
First, do you live within or off the reservation/ pueblo/
On/Within
Rancheria/ Alaska native village/ tribal service area?
Off
A2
SOURCE: Household Survey, Assessment of Native American,
Alaska Native, and Native Hawaiian Housing Needs (NAHSG)
(HUD/PD&R) [Objective 1.9]
Which of the following equipment or methods of food storage
and preparations do you use in your home . . .
A3
Gas/electric stove
Gas/electric oven
Wood stove
Microwave
Hotplate
Open fire
Refrigerator
Freezer
Root cellar
Ice house
Food canning
Food drying/dehydrator
Other….(SPECIFY)
SOURCE: Bell-Sheeter 2004, Food Sovereignty Assessment Tool
[Objective 1.10]
Who in your household has the major responsibility for
preparing meals?
(REFER TO HOUSEHOLD ENUMERATION, COLUMN 1, FOR
PERSON #)
Does (name of person) feel adequately prepared to cook the
food provided by FDPIR?
SOURCE: Project-developed question and response set.
A4
What is your main source of water for preparing meals? Is it…
● Public or private water system
● Individual well
●Spring
● Cistern
● Stream or lake
●Commercial bottled water
● Other (SPECIFY)?
Gas/Electric stove
Gas/electric oven
Wood stove
Microwave
Hotplate
Open fire
Refrigerator
Freezer
Root cellar
Ice house
Food canning
Food drying/dehydrator
Other SPECIFY): ______________
Person # ___
Yes
No
Don’t Know
Refused
Public or private water system
(includes city water)
Individual well
Spring
Cistern
Stream or lake
Commercial bottled water
Other (SPECIFY):
________________________
10
FDPIR Survey updated 9/10/11
A5.
Now I’d like to ask you some questions about the kinds of health
care services and insurance coverage used by members of your
household. Do you or your family receive any medical services
on the reservation/pueblo/Rancheria/Alaska native village/tribal
service area?
Yes
No
Don’t Know
Refused
IF YES: What are the sources of these services? (HAND
SHOWCARD X TO RESPONDENT) MARK ALL THAT APPLY
Tribal or IHS Health Center or
Clinic
Urban Indian Health Center
Tribally-managed or IHS Hospital
Tribal or IHS Mobile Clinic or Lab
(van)
Home visits (by a physician or
visiting nurse)
Traditional Healers
Community Health Representative
Wellness Center
Emergency Medical Services
Tele-health services
County/Local Health Center
County/Local Hospital
Managed Care Organization
Private doctor’s office
Local Public Health Department
Other (SPECIFY):
SOURCE: Project-developed question. Response categories
based on content analysis of Indian Health Service regions and
tribally-managed health services. [Objective 1.4]
11
FDPIR Survey updated 9/10/11
A6
A7
The next questions are about the types of health care plans and
what sources are available for medical care. Is anyone in the
household covered by health insurance or some other kind of
health care plan?
IF YES, ASK ABOUT EACH PERSON IN HOUSEHOLD.
Is anyone covered by:
1. Private Health Insurance
2. Medicare
3. Medicaid
4. Military Health Care (TRICARE, VA, and others)
5. State Sponsored Health Plan
6. Other Government Program
7. Single Service (E.G., dental, vision, prescriptions)
8. No coverage of any type
9. SCHIP – State Children’s Health Insurance Program
10. Other (SPECIFY):
11. DON”T KNOW
12. REFUSED
1. □ Yes
□ No
2. □ Yes
□ No
3. □ Yes
□ No
4. □ Yes
□ No
5. □ Yes
□ No
6. □ Yes
□ No
7. □ Yes
□ No
8. □ Yes
□ No
9. □ Yes
□ No
10. □ Yes
□ No
11. □ DON’T KNOW
12. □ REFUSED
Yes
No
Don’t Know
Refused
SOURCE: NHANES HEALTH INSURANCE QUESTIONNAIRE (HIQ)
[Objective 1.4]
I’m going to read you a list of common health problems. Does
anyone in your household currently have any of the following
health problems?
INTERVIEWER: IF ‘YES’ TO ANY CATEGORY (A8a THROUGH A8j)
ASK QUESTION AND ENTER # IN SPACE PROVIDED :
How many household members experience (name of category)?
A7a. High blood pressure …………………………………………………
A7b. Diabetes (sugar) ……………………………………………………….
A7c. Overweight/obesity ………………………………………………….
A7d. Heart disease …………………………………………………………
Yes #: ____
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
12
FDPIR Survey updated 9/10/11
A7e. Cancer ……………………………………………………………………
A7f. Underweight …………………………………………………………….
A7g. Liver disease …………………………………………………………..
A7h. Gastro-intestinal problems (e.g., Irritable Bowel
Syndrome, ulcers, lactose intolerance, diarrhea)
………………………………………………………………………..
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes (ASK A8a)
No
Don’t Know
Refused
Low salt #:___
Low sugar #: ___
Low fat #: ___
Lactose intolerant #: ___
Gluten intolerant #: ___
High protein #: ___
Food allergies #: ___
Other (SPECIFY): ______________
#: ___
A7i. Vitamin or mineral deficiencies or anemia ……………….
A7j. Other (SPECIFY)_______________..............................
A8
SOURCE: Based on Usher et al, 1990. [Objective 1.11]
Are there food items you or anyone in your household cannot or
should not eat? These could include foods that cause food
allergies, and foods needed for special diets and the like.
A8a) IF YES - What are they? (CODE ALL THAT APPLY) FOR
EACH RESPONSE ASK: How many persons in your household
have this restriction?
SOURCE: Project-developed question and response set.
[Objective 1.11]
13
FDPIR Survey updated 9/10/11
A9
A10
Now we’re going to change topics and talk about your housing
and utility expenses. Can you tell me whether you are buying
your home, own your home, renting, live rent-free or have some
other arrangement?
SOURCE: Usher et al, 1990 FDPIR Survey [Objective 1.9]
HAND SHOWCARD X TO RESPONDENT
Now I would like to ask about your rent or mortgage payments.
Do not include utilities. Please look at this card and show me
the amount you pay for your rent or mortgage each month. You
can just give me the letter if you prefer.
A11
SOURCE: Project-developed question and response set.
[Objective 1.9]
Now I would like to ask you about the amount you pay for
utilities each month. Please think about the total amount you
pay for gas, electricity, water, trash collection and telephone.
Look at this card and tell me how much you pay for utilities.
What utilities/services are included in that amount?
Own home
Renting
Other (SPECIFY): ______________
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
Less than $100
$100 to $199
$200 to $249
$250 to $299
$300 to $349
$350 to $399
$400 to $449
$450 to $499
$500 to $599
$600 to $699
$700 to $799
$800 to $999
$1,000 to $1,249
$1,250 to $1,499
$1,500 to $1,999
$1,500 to $1,999
$2,500 or more
No cash paid for rent/mortgage
Don’t know
Refused
A.
B.
C.
D.
E.
F.
G.
H.
Less than $100
$100 to $199
$200 to $249
$250 to $299
$300 to $349
$350 to $399
$400 to $449
$450 to $499
Gas
Electricity
Water
Trash collection
Telephone
Other (SPECIFY) __________
14
FDPIR Survey updated 9/10/11
Section B: FDPIR Contribution to Food Supply
These next questions are about the food eaten in your household in the last 12 months, since (current
month) of last year and whether you were able to afford the food you need.
B1
I am going to read you two statements and would like to know if
during the past 12 months, that would be from (month/year), if
these were often true for your household, sometimes true, or
never true for your household.
B1a. The first statement is, “The food that (I/we) bought just 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 last 12
months?
Often true
Sometimes true
Never true
Don’t Know
Refused
B1b. “(I/we) couldn’t afford to eat balanced, nutritious meals.”
Was that often, sometimes or never true for (you/your household)
in the last 12 months?
Often true
Sometimes true
Never true
Don’t Know
Refused
Yes
No (SKIP TO B1c1)
Don’t Know (SKIP TO B1c1)
Refused
Almost every month
Some months but not every
month
Only 1 or 2 months
Don’t Know
Refused
B1d. In the last 12 months, did you ever eat less than you felt you
should because there wasn’t enough money for food?
Yes
No
Don’t Know
Refused
B1e. In the last 12 months, were you/other adults in your
household ever hungry but didn’t eat because there wasn’t
enough money for food?
Yes
No
Don’t Know
Refused
B1c. In the last 12 months, since last (CURRENT MONTH), did
(you/you or other adults your household) ever cut the size of your
meals or skip meals because there wasn’t enough money for food?
B1c1. IF YES ABOVE, ASK How often did this happen –
almost every month, some months but not every month,
or in only 1 or 2 months?
SOURCE (B1a-e): US Household Food Security Survey Module:
Six-Item Short Form[HH3, HH4, AD1, AD1a, AD2, AD3]
15
FDPIR Survey updated 9/10/11
B2
How did you learn about FDPIR? (RECORD VERBATIM and CODE
ANSWER)
B3
SOURCE: Project-developed question and response set.
[Objective 5.1]
Is FDPIR the only or primary source of food for this household?
B3a. Thinking of the other sources of food for this
household, what percentage comes from:
(READ CATEGORIES BELOW AND HAND RESPONDENT
SHOWCARD X).
FDPIR
Other food programs to include, for example,
National School Lunch Program, WIC, Meals on
Wheels
Extended family or tribal community
Grocery/supermarket/convenience store
Traditional/native food sources (hunting, fishing,
berry picking, ricing, gardening, farming)
Food pantries or food banks
Take-out or convenience stores
Other (SPECIFY)
Prior receipt of FDPIR foods by
household
Word of mouth (family, friend)
Referral from tribal social service
program (SPECIFY):
___________
Tribal newsletter or brochure
Outreach by FDPIR staff
(SPECIFY): _________________
Referral from county social
services
Other (SPECIFY): ____________
Yes only source of food (SKIP TO
SECTION C)
No there are other sources (ASK
B3a)
Don’t Know
Refused
____% FDPIR
____% Other Food programs
____% Extended family or tribal
community
____% Grocery/ supermarket/
convenience store
____% Traditional/native food
sources
____% Food pantries/food banks
____% Take-out
____% Other (SPECIFY): __________
INTERVIEWER: INDICATE THE PERCENTAGES OF EACH. THE TOTAL
SHOULD ADD UP TO NEAR 100%.
SOURCE: Project-developed question and response set.
[Objective 2.1, 2.3]
16
FDPIR Survey updated 9/10/11
B4
Is anyone in your household receiving benefits from or
participating in food programs other than FDPIR? Examples would
include (READ CATEGORIES BELOW AND HAND RESPONDENT
SHOWCARD X).
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food Program
Summer Feeding Program or the Summer Food Service
Program
Elderly Meals/Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local programs, other tribal programs
WIC Farmers’ Market Nutrition Program
Seniors Farmers’ Market Nutrition Program
Soup Kitchens
Any others
B4a. IF YES: Which ones?
Yes
No
Don’t Know
Refused
□
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food
Program
Summer Feeding Program or the
Summer Food Service Program
Elderly Meals/ Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local
programs, other tribal programs
WIC Farmers’ Market Nutrition
Program
Seniors Farmers’ Market
Nutrition Program
Soup Kitchens
Other programs(SPECIFY):
_____________________
B5
SOURCE: National Survey of WIC Participants and Their Local
Agencies, Section E Household Income and Food Spending with
some project developed items. [Objective 2.2]
Has anyone in your household referred to other food programs by
the FDPIR staff? Examples would include (READ CATEGORIES
BELOW AND HAND RESPONDENT SHOWCARD X).
Yes (ASK B5a)
No (SKIP TO B6)
Don’t Know
Refused
□
□
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food Program
Summer Feeding Program or the
Summer Food Service Program
Elderly Meals/ Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local programs,
other tribal programs
WIC Farmers’ Market Nutrition
Program
Seniors Farmers’ Market Nutrition
Program
Soup Kitchens
Other programs(SPECIFY):
B5a. IF YES: Which programs?
_____________________
17
FDPIR Survey updated 9/10/11
B6
Yes
No
Don’t know
Refused
None
Some
About half
Most
During the past month did you or anyone in your household get
any meals that were prepared by extended family or prepared by a
community group?
□
□
□
Yes
No
Don’t Know
Refused
B7A. IF YES: How often did the household eat meals
prepared by extended family or prepared by a community
group? Would you say none, some, about half or most
meals?
None
Some
About half
Most
I am going to ask you about the sources of meals for your
household. By meals I mean breakfast, lunch and dinner. During
the past month did you or anyone in your household get any meals
that were prepared away from home in places such as restaurants,
fast food places, food stands, grocery stores, or from vending
machines? Do not include meals prepared by extended family or in
a community setting.
B6a. IF YES: About how often did the household eat
meals prepared by such places as restaurants, fast food
places, food stands, grocery stores, or from vending
machines? Would you say none, some, about half, or
most?
SOURCE: National Health and Nutrition Examination Survey
(NHANES) [Objective 2.1]
B7
SOURCE: Project-developed question and response set.
[Objective 2.1]
18
FDPIR Survey updated 9/10/11
Section C: Access to FDPIR - Distribution and Delivery
The next set of questions covers access to the Food Distribution Program in terms of the distance and
time it takes to travel to sites for enrollment, certification, and picking up the food package. There are
also a few questions on the time spent and distances traveled for other sources of food.
C1
When you applied for the FDPIR program approximately how many miles
did you have to travel to the certification site?
C1a. About how long did it take to get there?
___ HRS
C1b. What kind of transportation did you use? Was it your own car
or truck, someone else drove you, you walked, took public
transportation, taxi or some other way?
1. Own car or truck
2. Someone else drove
SPECIFY:
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY: ________________
SOURCE: Project-developed question and response set. [Objective 1.7]
C2
___ Miles
INTERVIEWER: IF THE ANSWER TO C2 IS AVAILABLE PLEASE FILL IN BEFORE
INTERVIEW AND DO NOT ASK THIS QUESTION.
What is your current period of certification? Are you required to recertify
every 1-2 months, every 3-5 months, every 6-11 months or more than a
year?
SOURCE: Project-developed question and response set. [Objective 1.2]
C3
___ MINS
Different places offer several options for getting/picking up the food
package. These options include pickup at FDPIR site, FDPIR store/nutrition
centers, different warehouse location, tailgate location, and home delivery.
Which option do you usually use when getting your food package?
C3a. Are you satisfied with this method?
IF NO: What would you prefer? (RECORD VERBATIM and CODE
ANSWER)
1-2 months
3-5 months
6-11 months
Year or more
Other (SPECIFY)
Don’t know
FDPIR Site
FDPIR Store/Nutrition
Center
Different Warehouse
location
Tailgate Location
Home Delivery (SKIP TO
D1)
Other (SPECIFY):______
_______________________
Yes
No
Don’t Know
Refused
SOURCE: Project-developed question and response set. [Objective 9.1]
19
FDPIR Survey updated 9/10/11
C4
Thinking about picking up your food packages, approximately how many
miles do you have to travel to pick up the food packages?
___ Miles
C4a. About how long does it usually take to get there?
___ HRS
C4b. What kind of transportation do you usually use? Is it your
own car or truck, someone else drove you, you walked, took public
transportation, taxi or some other way?
1. Own car or truck
2. Someone else drove
SPECIFY: ________________
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY: ________________
SOURCE: Project-developed question and response set. [Objective 1.7]
C5
Do you have an authorized representative pick up your food packages?
Yes
No
Don’t Know
Refused
C5a. IF YES: Approximately how many miles does the
representative travel to pick up the food packages?
___ Miles
C5b. About how long does it usually take your representative to get
there?
___ HRS
C5c. What kind of transportation does he/she use? Is it their own
car or truck, they walked, took public transportation, taxi or some
other means of transportation?
SOURCE: Project-developed question and response set. [Objective 1.7]
C6
Does traveling to the FDPIR site present any challenges or problems for
you?
[Objective 4.4]
SOURCE: Project-developed question and response set. [Objective 1.7]
___ MINS
1. Own car or truck
2. Someone else drove
SPECIFY: ________________
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY:________________
Yes
No (SKIP TO C7)
Don’t Know
Refused
Yes
No
Don’t Know
Refused
C6a. IF YES, please describe why this is challenging (SPECIFY).
C6b. Is home delivery an option that is offered by the FDPIR
program?
___ MINS
20
FDPIR Survey updated 9/10/11
Section D: Food Access and Cost – Non-subsidized Sources
We are also interested in finding out how easy or hard it is to obtain food in your area and about food
costs.
D1
We are also interested in the distance of other food outlets/suppliers/sources
than FDPIR from your home. Approximately how many miles is the nearest
(CATEGORY) and what is the travel time to get there?
D1a. Nearest food retail store that sells fresh produce ……………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1b. Nearest grocery store………………………………………………………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1c. Nearest convenience store……………………………………………………………………….
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1c. Nearest farmers market………………………………………………………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1d. Nearest warehouse store or department store such as Target……………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1e. Nearest Wal-Mart that sells groceries…………………………………………………………
D2
Thinking about the past year, that would be from about , have
there been any changes in your access to food sources. Examples of changes
could be opening or closing of supermarkets, changes in food programs and the
like.
____Miles
___ Hrs/Mins
Don’t Know
Refused
Yes (ASK D2a)
No (SKIP TO D3)
Don’t Know
Refused
D2a. IF YES: What are these changes? (RECORD VERBATIM)
SOURCE: Project-developed question and response set.
21
FDPIR Survey updated 9/10/11
D3
On average, what does your household spend each month on food (including
food consumed at home and food consumed outside the home)?
$_____
D3a. Are there seasons when your household spends considerably less
on food expenses?
D3b. Which seasons?
SEASON: ___________
SEASON: ____________
D3c. Why is that? RECORD VERBATIM:
Yes
No (SKIP TO D4)
Don’t Know
Refused
___________________________________________________________
D3d. Are there seasons when you household spends considerable more
on food expenses? (IF NO, SKIP TO SECTION E)
D3e. Which seasons?
Yes
No (SKIP TO
SECTION E)
Don’t Know
Refused
SEASON: ___________
SEASON: ____________
D3f. Why is that? RECORD VERBATIM
SOURCE: Project-developed question and response set.
22
FDPIR Survey updated 9/10/11
Section E: Participation in FDPIR and SNAP/Food Stamps
The next few questions will be about whether your household has also participated in SNAP/Food Stamp
program as well as FDP, if you have ever switched between the two programs, and your reasons for
doing so.
E1
INTERVIEWER: IF AVAILABLE ENTER THE MONTHS OF PARTICIPATION INFORMATION FROM AIS IN THE
CHART BELOW.
IF ALL MONTHS ARE FILLED IN FOR FDPIR/SNAP: SKIP TO QE5.
IF THERE ARE MONTHS WHERE THERE ARE GAPS IN PARTICIPATION FOR FDPIR/SNAP: SKIP TO QE2.
IF AIS INFORMATION IS NOT AVAILABLE: CONTINUE BELOW.
INTERVIEWER: ON THE FIRST LINE UNDER MONTH IN THE CHART BELOW ENTER THE NEXT MONTH FROM
THE INTERVIEW. (IF YOU ARE CONDUCTING THE INTERVIEW IN MARCH – ENTER APRIL). CONTINUE TO FILL
IN THE MONTHS. THE LAST MONTH ENTERED WILL BE THE CURRENT MONTH. THEN ENTER THE YEAR THAT
CORRESPONDS TO EACH MONTH TO SHOW THE LAST YEAR UP UNTIL THE INTERVIEW. HAND R SHOWCARD
X.
ALL MONTH LINES NEED TO HAVE AN ENTRY IN ONE OF THE LAST THREE COLUMNS.
E1a. Thinking of the past year, that would be from until now, what months did you
participate in a food program? Let’s start with . During this month were you participating in
SNAP/Food Stamps, FDPIR or neither? CONTINUE ASKING ABOUT EACH MONTH.
MONTH
YEAR
SNAP
FDPIR
NEITHER
2013
[Objective 3.2]
23
FDPIR Survey updated 9/10/11
E2
I see that you did not participate in either FDPIR or SNAP in ? Can you tell me why? THIS MAY INVOLVE CONSECTUTIVE OR NONCONSECUTIVE MONTHS. ASK ABOUT ALL MONTHS AND LIST UNTIL ALL
REASONS HAVE BEEN ACCOUNTED FOR.
(RECORD VERBATIM AND CODE)
SOURCE: Project-developed question and response set. [Objective 3.2]
E3.
Was not eligible (income
related reason)
Did not apply in time
Was receiving food
benefits through another
household
Had other sources of
food (personal,
community)
Did not live in the area
Other (SPECIFY): _____
I see that you changed from FDPIR to SNAP/Food Stamps in
. What was the reason/were the reasons for changing
from FDPIR to SNAP?
HAND RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD.
MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL
CHANGES HAVE BEEN ACCOUNTED FOR.
A. Because the size and income resources of my household
changed so I was now eligible for SNAP [change in eligibility]
B. Because I participate in the TANF program
C. Because I prefer having a greater variety of food choices or
options [greater food choices]
D. Because the food in the store/supermarket is better quality
than the USDA Foods [better food quality]
E. Because I have less time to prepare and cook food , don’t
know how to cook, don’t like to cook or don’t have the time to
cook, needed greater flexibility and can buy convenience and
prepared foods [greater convenience in food preparation]
F. Because I needed to buy specific foods for household
members (e.g., dietary restrictions) [changes in household
food/dietary needs]
G. In the summer I have more responsibility for feeding children
not in school.
H. Because I have greater privacy obtaining food using the EBT
card [personal preference; privacy]
I. Because I can use the EBT card at a convenience store or gas
station [greater convenience]
J. Because the store/market is closer to where I live than the
distribution site [better access, more convenient]
K. Because I was going away for a period of time and would be
able to use SNAP benefits anywhere [greater convenience]
L. Because I think I can get more food on SNAP benefits than
FDPIR
M. Because . . . [Respondent supplies reason] [Other]
SWITCH FDPIR to SNAP
A
B
C
D
E
F
G
H
I
J
K
L
M
[Objective 3.31]
24
FDPIR Survey updated 9/10/11
I see that you changed from SNAP/Food Stamps to FDPIR in
. What was the reason/were the reasons for
changing from SNAP to FDPIR?
HAND RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD.
MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL
CHANGES HAVE BEEN ACCOUNTED FOR.
A. Because it is easier to qualify for FDPIR [lower income threshold]
B. Because I receive a greater quantity of food through FDPIR
[increased food quantity]
C. Because the quality of the USDA Foods is better [better food
quality]
D. Because I wanted to stock up on canned and dried goods
[stocking up on food]
E. Because I don’t like the SNAP/food stamp certification process,
because I don’t like the way I am treated at the county office or
similar problem. [dissatisfaction with certification process]
F. Because the county office is too far way and difficult to get to
[inconvenient location]
G. Because the FDPIR pick-up/distribution site is closer than going to
the store/market [easier access]
H. Because I don’t know how to use/feel comfortable using an EBT
card [personal preference; discomfort with using EBT]
I. Because I feel that people in the store/market look down on me
when I use the EBT card [perception of stigma]
J. Because . . . [Respondent supplies reason] [Other]
E4
E5
SOURCE: Project-developed question and response set based on content
analysis of 2009 Urban Institute site visit reports, review of Usher et al 1990,
and comments during January 2012 USDA/FDPIR Tribal Consultations
[Objective 3.3]
You said that your household received SNAP/Food Stamps during the last
year. About how much was the amount received each month?
Has any member of the household ever been disqualified from participation
in the FDPIR program?
IF YES: Please explain:(RECORD VERBATIM)
SWITCH SNAP to FDPIR
A
B
C
D
E
F
G
H
I
J
$______ Monthly
Yes
No
Don’t Know
Refused
25
FDPIR Survey updated 9/10/11
Section F: Nutrition Education and Other Services
The next few questions ask about nutrition education and other health related services.
F1
FDPIR offers nutrition education information and activities on-line and
in person. Examples of these include distributing newsletters,
factsheets, recipes, providing nutrition counseling, or holding cooking
demonstrations and nutrition classes. Have you or anyone in your
household used or taken part in any of these activities in the past year?
F1a. IF NO: Was this because they were not offered, no one
was interested, considered to be not useful, no
computer/internet access, timing not good, location
inconvenient, no transportation or some other reason.
(RECORD VERBATIM AND CODE)
F1b. IF YES, HAND SHOWCARD TO R: I am going to read you a
list of items, please tell me if during the past year anyone in
your household picked up any of the educational offerings or
took part in any of the activities that included nutrition
education . . . (READ EACH CATEGORY AND CHECK () THE ‘YES’
CATEGORIES )
IF CHECKED: Approximately how often?
Newsletters ………………………………….
Factsheets ……………………………………
Recipes/Cookbooks ………………………
DVDs …………………………………………….
Calendars ………………………………………
How to budget ………………………………
How to grocery shop ……………………..
Cooking demonstrations ………………..
Baking demonstrations ………………….
Demonstrations on how to preserve
food ………………………………………………
Demonstrations on using traditional
foods …………………………………………….
Tastings during FDP pick-up …………..
Nutrition classes ……………………………
Nutrition counseling ……………………..
‘Pot luck’ or similar types of
gatherings …………………………………….
Kid nutrition …………………………………
Mothers’ Groups …………………………
Demonstrations on or participation
in gardening ………………………………….
Yes
No
Don’t Know
Refused
Not offered
Not interested
Not useful
No computer/ internet access
Timing not good
Location inconvenient
No transportation
Other (SPECIFY): ___________
_________________________
Don’t Know
Refused
FREQUENCY (PER YEAR)
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
26
FDPIR Survey updated 9/10/11
Gardening education …………………….
Health/Nutrition fairs ……………………
Other (SPECIFY): ________________
Other (SPECIFY): ________________
____ Times
____ Times
____ Times
____ Times
____ Times
IF F1b RESPONSES ARE ALL NOT CHECKED SKIP TO F2.
IF ANY CHECKED IN F1b ASK F1c.
F1c. You indicated someone in the household read or
participated in the following FDPIR offerings . Have any changes been made to the
household cooking or eating practices as a result of these
programs, activities, or information?
F1d. IF YES: What changes have been made? RECORD
VERBATIM
___________________________________________________
___________________________________________________
F1e. IF NO: Why not? RECORD VERBATIM
___________________________________________________
__________________________________________________
F2
SOURCE: Project-developed question and response set, based on
content analysis of 2009 Urban Institute site visit reports.
[Objective 6.3]
Other program services offered by FDPIR alone or in coordination with
other programs are fitness and health classes, cooking classes, health
fairs and the like. Have you or anyone in your household taken part in
such activities?
F2a. IF YES to F2: Were there any changes in activity or health/fitness
because of these services/activities?
IF YES TO F2a1: What were the changes?
Yes (ASK F2a)
No (SKIP TO F3)
Don’t Know
Refused
Yes (ASK F2a1)
No (ASK F2a2)
Don’t Know
Refused
IF NO TO F2a2: Why not?
27
FDPIR Survey updated 9/10/11
F2b. IF YES to F2: Were there any changes in diet and health because
of these services/activities?
IF YES TO F2b1: What were the changes?
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
IF NO TO F2b2: Why not?
F2c. IF YES to F2: Were there any changes in food preparation because
of these services/activities?
IF YES TO F2c: What were the changes?
IF NO TO F2c: Why not?
SOURCE: Project-developed question and response set. [Objective 6.2]
F3
Has FDPIR staff ever referred your household to other assistance
services or programs like cash assistance or child support for example?
F3a. If YES, which one(s)? CHECK ALL THAT APPLY. PROVIDE
A CARD WITH THE LIST
Head Start
Tribal TANF
Emergency Assistance
General Assistance
Elder Care
Subsidized Housing
Child Support
Indian Child Welfare
Vocational Education
Vocational Rehabilitation
Health & Wellness
Mental Health
Domestic Violence
Substance Abuse
Other (SPECIFY):
____________
28
FDPIR Survey updated 9/10/11
F3b. Are any of these programs or services provided in the
same location as FDPIR?
If YES, which one(s)?
CHECK ALL THAT APPLY
SOURCE: Project-developed question and response set.
[Objective 5.5]
Yes
No
Don’t Know
Refused
Head Start
Tribal TANF
Emergency Assistance
General Assistance
Elder Care
Subsidized Housing
Child Support
Indian Child Welfare
Vocational Education
Vocational Rehabilitation
Health & Wellness
Mental Health
Domestic Violence
Substance Abuse
Other (SPECIFY):
____________
29
FDPIR Survey updated 9/10/11
Section G: Satisfaction with FDPIR
We are now going to talk about your satisfaction with FDPIR.
G1
HAND RESPONDENT SHOWCARD X
What was your household’s most important reason for seeking food
assistance? (RECORD VERBATIM AND CODE ANSWER)
a.
b.
c.
d.
e.
SOURCE: Project-developed question and response set.
f.
g.
h.
G2
HAND RESPONDENT SHOWCARD X
What was your household’s most important reason for enrolling in FDPIR?
(RECORD VERBATIM AND CODE ANSWER)
a.
b.
c.
d.
Loss of job
Loss of other source of
income
Household became
eligible for FDPIR
FDPIR was more
convenient than other
programs
FDPIR changed its
delivery options and it
became easier for our
household
Loss of other benefits
Established own
household
Other (SPECIFY)
Household became
eligible for FDPIR
FDPIR was more
convenient than other
programs
FDPIR changed its
delivery options and it
became easier for our
household
Other (SPECIFY)
SOURCE: Project-developed question and response set.
G3
FDPIR offers a variety of foods including vegetables, dry beans, juice, fruits,
meats, ready to eat cereals, and miscellaneous items such as dry egg mix,
cheese, crackers, noodles, peanut butter, milk and pasta to name a few.
G3a. In terms of variety how satisfied are you? Very satisfied,
somewhat satisfied, neither satisfied or dissatisfied, somewhat
dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3b. In terms of freshness how satisfied are you? Very satisfied,
somewhat satisfied, or not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
30
FDPIR Survey updated 9/10/11
Very dissatisfied
G3c. In terms of quality how satisfied are you? Very satisfied,
somewhat satisfied, neither satisfied or dissatisfied, somewhat
dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3d. In terms of nutritional value how satisfied are you? Very
satisfied, somewhat satisfied, neither satisfied or dissatisfied,
somewhat dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3e. In terms of taste appeal (PROBE: salty, sweet, sour, old, stale,
greasy) how satisfied are you? Very satisfied, somewhat satisfied,
neither satisfied or dissatisfied, somewhat dissatisfied or very
dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3f. In terms of visual appeal of packaging and food how satisfied
are you? Very satisfied, somewhat satisfied, neither satisfied or
dissatisfied, somewhat dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3g. What is your overall satisfaction with the FDPIR food package?
What do you like most? What do you like least? What foods would
you like to see added? Are any of these food considered
cultural/traditional foods?
IF NOT SATISFIED: Why are you not satisfied?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
SOURCE: Project-developed question and response set. [Objective 9.1]
31
FDPIR Survey updated 9/10/11
G4
Generally, do you, and members of your household, feel that the FDPIR
programs meets your food and nutrition needs?
G4a IF YES: Could you tell me more about how it has met your food
and nutrition needs? (RECORD VERBATIM)
Yes (SKIP TO G4a)
No (SKIP TO G4b)
Don’t Know
Refused
G4b IF NO: Could you tell me more how the program has not met
your food and nutrition needs? (RECORD VERBATIM)
SOURCE: Project-developed question and response set. [Objective 9.1]
G5
Please tell me your overall satisfaction about the following aspects of your
experiences with FDPIR. Are you very satisfied, somewhat satisfied or not
satisfied with the following aspects of FDPIR:
IF NOT SATISIFIED ASK: What is the reason you are/were not satisfied?
G5a. Application process
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5b. Recertification process
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5c. Location of distribution site
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5d. Attractiveness/atmosphere of distribution site
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
32
FDPIR Survey updated 9/10/11
Very dissatisfied
G5e. Features of the distribution facility
[PROBES: Sufficient parking, children’s play area, help carrying FDPIR
food package items to the car]
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4f. Frequency of distribution
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4g. Interaction with program staff
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4h. Nutrition Education offerings
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4i. Other program factors (SPECIFY) :_________________________
SOURCE: Project-developed question and response set. [Objective 9.1]
G6
Have there been any changes in FDPIR in the past three years that have
influenced your participation in the program?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Yes (SKIP TO G5A)
No
Don’t Know
Refused
G5a. IF YES: What changes? (RECORD VERBATIM)
33
FDPIR Survey updated 9/10/11
G5b. How did the changes influence your participation? (RECORD
VERBATIM.)
SOURCE: Project-developed question and response set.
G7
If you had the opportunity what would you tell the Federal Government about
the FDPIR program? (RECORD VERBATIM – PROBE FOR COMPLETENESS)
Nothing/No
comment
Refused
SOURCE: Project-developed question and response set, based on Bell-Sheeter,
2004.
G8
G9
If you had the opportunity what would you tell your tribal leaders about the
FDPIR program? (RECORD VERBATIM – PROBE FOR COMPLETENESS)
SOURCE: Project-developed question and response set, based on Bell-Sheeter,
2004.
Would you recommend the FDPIR program to other family and friends?
G8a. IF NO: Why not? (RECORD VERBATIM)
Nothing/No
comment
Refused
Yes
No
Don’t Know
Refused
SOURCE: Project-developed question and response set.
34
FDPIR Survey updated 9/10/11
Section H: Ending the Interview
Those are all of the survey questions I have. Thank you so much for taking the time to speak with me.
Do you have any questions about the survey or the experience?
H1
In appreciation for the time spent with me the project would like to give you
$25.00/gift card. HAVE RESPONDENT SIGN THE RECEIPT.
H2
The office may want to call you to verify that the interview was conducted.
What is the best phone number to reach you?
H2a. What is the best time of day to reach you? Morning, afternoon
or evening?
$25.00
Gift Card
___ - ___ - ____
1.
2.
3.
AM
PM
Evening
H3
DATE OF INTERVIEW: _____/_____/_____
INTERVIEWER NAME: ______________________________________
ID NUMBER: _________________________
IS THERE ANYTHING YOU WOULD LIKE TO SAY ABOUT THIS INTERVIEW?
Time Ended: __:____
35
ACOMA FOOD DISTRIBUTION PROGRAM
P.O. Box 449
Acoma, New Mexico 87034
Telephone: (505) 552-9489 Fax: (505) 552-6536
Instructions: Complete the following information. If you refuse to cooperate/provide verification, your
application will be denied. You must provide proof/verification of all income and allowable deductions.
Name (Head of Household):
County:
Physical Address:
Telephone No.:
Mailing Address:
Application Date:
NEW or RECERT.
City/State/Zip Code:
HOUSEHOLD MEMBERS: Complete the following for each member of your household. Your household means yourself and
the people who live with you. List your name first. (Attach a separate sheet if you need to list additional household members.)
NAME(S) OF ALL HOUSEHOLD MEMBERS
(Last, First, Middle Initial). Please Print.
1.
RELATIONSHIP TO HEAD
OF HOUSEHOLD
(self, spouse, daughter, son, cousin, etc.)
DATE OF
BIRTH
SOCIAL SECURITY #
SELF
2.
3.
4.
5.
6.
7
8.
9.
Are you or anyone in your household currently receiving food stamps? Yes No If yes, list names: _
___
Have you or anyone in your household recently applied for Food Stamps? Yes No If yes, list names:
_______ __
__
Have you or anyone in your household been disqualified from the Food Stamp Program for an intentional program
violation? Yes No. If yes, list name(s):
INCOME (EARNED & UNEARNED): List income from all sources for each household member including wages, social
security, SSI, TANF, general/public assistance, foster care payments, unemployment or worker’s compensation, child support,
alimony, pensions, Veteran’s benefits, per capita payments from gambling enterprises, work/training allowances, etc.
Verification of income is required for all household members (pay check stubs, award letters, etc.). Households with earned
income must provide a full month’s wage statements. Attach a separate sheet, if you need to list additional household members.
TYPE OF INCOME
HOUSEHOLD MEMBER
EMPLOYER/
SOURCE OF INCOME
(Wages, Social Security,
TANF, Child Support, etc.)
GROSS
AMOUNT
HOW OFTEN PAID
Monthly, Bi-weekly, Weekly
SELF-EMPLOYMENT INCOME: Are there any members in your household who are self-employed? Yes No If yes,
complete the following section. Payment from rental property, roomers, boarders, farming, ranching, and/or operating your own
business is considered to be self-employment. Please provide a copy of last year’s Federal Income Tax form (1040, Schedules
F, C, E, if applicable, or other proof of self-employment costs and income (current books showing income and expenses).
HOUSEHOLD MEMBER
TYPE OF BUSINESS
(Farm, Ranch, Rental, Day care, etc)
OCCUPATION
Is your self-employment the
primary source of income for
meeting your living expenses?
STUDENTS: Are there any students in your household who receive education grants, scholarships or loans? Yes No
If yes, complete the following section. Please provide verification.
HOUSEHOLD MEMBER
AMOUNT OF
LOAN/GRANT
PERIOD OF TIME
FUNDS INTENDED
TO COVER
TYPE OF PAYMENT
(Pell Grant, Student
Loan, BIA)
Amount Used to pay
Tuition/School Fees
RESOURCES: List resources for all household members, except roomers and boarders. (Attach additional names on a separate
sheet).
HOUSEHOLD MEMBER
CASH ON HAND
CHECKING/SAVINGS
ACCOUNT
STOCKS, BONDS, CERTIFICATE
OF DEPOSIT, OTHER
ALLOWABLE DEDUCTIONS [Please provide verification]:
DEPENDENT CARE: Does anyone in your household pay for the care of a child or other dependent when necessary for a
household member to accept or continue employment or to attend training or pursue education which is preparatory to
employment? Yes No If yes, name and address of person providing care:
________
Amount Paid: $
How often paid (weekly, monthly, etc.)
CHILD SUPPORT: Does anyone in your household pay court ordered child support for a non-household member? Yes No
If yes, complete the following: Amount ordered to pay: $
Amount actually paid: $ _____________
MEDICARE: Does anyone in your household pay Medicare Part B Medical Insurance and/or Part D Prescription Drug
Coverage? Yes No If yes, complete the following: Household Member:
_______________________
Amount Paid for Part B: $____________
Amount Paid for Part D: $_______________
AUTHORIZED REPRESENTATIVE: To authorize someone outside your household to pick up your food, complete this section.
NAME(S)
ADDRESS
TELEPHONE NUMBER
RACIAL/ETHNIC DATA COLLECTION: This information is voluntary. If you do not provide this information, it will not affect
your eligibility.
1. Are you Hispanic or Latino? Choose one of the following:
Yes or No
2. What is your race? Choose any of the following that apply:
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
FAIR HEARING: If you disagree with any action taken on your case, you or your representative have the right to request a fair
hearing. You may request a fair hearing in writing or orally. If you request a fair hearing, your case may be presented by a
household member or representative, such as a legal counsel, a relative, a friend or other spokesperson.
PENALTY WARNING: If your household receives commodity food, it must follow the rules below. Failure to comply with these
rules may result in a monetary claim being filed against the household and /or disqualification from participation in the Food
Distribution Program.
1.
2.
3.
Do not make false or misleading statements, misrepresent, conceal, or withhold facts regarding income,
resources, household size, and/or participation in the Food Stamp Program in order to obtain Food Distribution
Program benefits which your household is not entitled to receive.
Do not trade or sell commodity food.
Do not participate simultaneously in the Food Stamp Program and Food Distribution Program.
INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES: If you or any member of your household knowingly and willing
violates the rules above it is considered an Intentional Program Violation (IPV). Household members determined to have
committed an IPV will be ineligible to participate in the Food Distribution Program for a period of 12 months for the first
violation, for a period of 24 months for the second violation; and permanently for the third violation. Individual(s) committing an
IPV may be referred to authorities for prosecution.
AUTHORIZATION: I authorize the release of any necessary information or forms to the Food Distribution Office from
individuals, businesses, schools, banking institutions, Federal/State/Tribal agencies needed to determine/verify my eligibili ty. I
understand that this information will be used only for the purpose of helping to document my eligibility for Food Distribution
benefits. This authorization is good for 12 months from the date signed or until revoked by me in writing.
CERTIFICATION STATEMENT: I certify that I have read this application and that the information contained in it is true and
correct to the best of my knowledge. I understand that I must comply with Program rules and provide additional documentation
if required, and that falsification of information on this form may be grounds for disqualification and/or claim action. I further
understand that I must report any changes in household size, income and/or resources to the Food Distribution Office within ten
days of the date the change becomes known.
Applicant’s Signature
Date
“In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race,
color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Office of Adjudication
and Compliance, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).
USDA is an equal opportunity provider and employer.”
FDPIR Application Form Rev. 11/06
# 5 – Letter to respondents
(date)
Dear Sir/Madam,
We are writing to let you know that you have been randomly selected to take part in a very important
national survey of food distributions on native lands and to request your assistance. It is called the
Study of the Food Distribution Program on Indian Reservations (FDPIR). is one of only 25 selected from across the country.
The food distribution study is funded by the U. S. Department of Agriculture (USDA) and is being
conducted by Urban Institute and NORC at the University of Chicago. This study will provide current
nationally representative information on FDPIR participants and also provide updated information on
local program operations across the nation.
The survey will take about 45 minutes to complete. Some of the topics covered include FDPIR and other
contributions to your food supply, food costs, health and diet concerns, use of other food assistance
programs, nutrition education, and your overall satisfaction with the food distribution program.
We have been given approval by your for
your participation.
Over the next few weeks an interviewer from NORC will be contacting you about participation in the
survey. The interviewer is prepared to answer any questions you may have. In the meantime please
feel free to call our toll free number with any questions you may have. That number is 800-XXX-XXXX.
Also, please see the enclosed brochure for more information.
Thank you so much for reading this letter and considering our request.
Sincerely,
Signatures and logos
BROCHURE – RESPONDENT INTERVIEW VERSION
Panel 1: Cover
Topic: Name of study
Notes: Will also include food and food distribution pictures
Study of the Food Distribution Program on Indian Reservations
Panel 2: Inside Left
Topic: Description of Project
This important and timely study is being conducted for the United States Department of Agriculture
(USDA) Food and Nutrition Service (FNS). NORC at the University of Chicago will be conducting the
survey of participating households and is working in collaboration with the Urban Institute and Support
Services International.
The FDPIR study will provide current, nationally representative information on FDPIR participants and
will provide updated information on local program operations across the nation.
The last nationally representative study of FDPIR participants and programs was completed in 1990.
Since then, many changes have occurred in the FDPIR program, including changes to eligibility rules,
foods offered, and food delivery options. This study is needed to measure progress and see what else
can be done to better serve the community.
Twentyfive reservations/Tribal service areas were randomly sampled using a scientific method to take
part in the household survey. Since all reservations and Tribal areas could not be included in the study,
and only a sample of respondents could be selected from each reservation/Tribal service area, you will
be speaking for many others just like yourself. Your interest and participation is greatly appreciated.
Overall, the sites selected will include a representation of many areas across Indian Country. For
example:
Native American Reservations in 11 states
Tribal Service Areas in Oklahoma
1
Panel 3: Inside Middle
Topic: Continuation of Project Description
A NORC interviewer will call or visit your home to discuss your participation and answer any questions
you may have. He/she will show you proper identification and will also have additional materials to
share with you about the project. There is also a toll free number (800-XXX-XXXX) to call if you have any
questions about the interview or the interview process. In addition you can call NORC’s Institutional
Review Board toll free at 866-309-0542 to verify the legitimacy of the study.
The survey questions are easy to answer and cover topics you are very familiar with. You will be asked,
for example, about your household obtains food and its costs, health and diet concerns, FDPIR’s
contribution to your food supply, your satisfaction with FDPIR, nutrition education and other services.
Your participation is voluntary. If you don’t want to answer certain questions, that’s OK too.
If you agree to participate, the interview will take about 30 minutes and you will receive a $25 gratuity
to express our appreciation for your time.
Panel 4: Inside Right
Topic: Questions and Answers
Why is it so important that I participate? You were scientifically selected and represent many people like
yourself. Those selected cannot be replaced. Your valuable input would be lost. Remember, the interviewer will
answer any questions you have and is willing to conduct the interview at any time convenient for you.
WILL ANYONE FIND OUT WHAT MY ANSWERS ARE? Absolutely not. Your answers and name/address are
never linked together. The answers from all people taking the survey are grouped together. All NORC interviewers
sign a pledge of confidentiality not to reveal any names of participants or discuss the project with anyone besides
the survey staff.
DOES MY TRIBAL COUNCIL KNOW ABOUT THIS PROJECT? Yes, we have received permission from the Tribal
leaders to conduct the survey in your community. Your interviewer will give you the specific information on how
permission was given and by whom. Also be assured that these officials do NOT know the addresses, names, or
answers of anyone participating in the household interview. That is confidential information only known by the
study staff.
WHAT HAPPENS IF I DECIDE NOT TO PARTICIPATE? That’s OK. Participation is completely voluntary. No one
except the study staff will know you refused to participate. Your decision will have no effect on your household’s
food assistance benefits.
DOES THE INTERVIEW HAVE TO BE CONDUCTED IN MY HOME? No. If you prefer we can do the interview
over the phone or at another place of your choice.
2
Panel 5: Back left
Topic: Description of Urban Institute, and NORC at the University of Chicago,
and SSI
URBAN INSTITUTE
The Urban Institute, a nonprofit research organization based in Washington, DC, prides itself on
producing policy-oriented research that is objective, based on evidence, and reliable. As with all of its
research, the Institute has no “agenda” with respect to Native American or Alaska Native persons or the
FDPIR Program other than an interest in seeking to understand the policies and program features that
work and work best. The Institute’s research team combines outstanding research skills with knowledge
of Native American-focused programs and of food assistance programs.
NORC at the UNIVERSITY OF CHICAGO
NORC is an independent non-profit research organization that conducts social science research that
serves the public good. NORC works with federal agencies, Tribes, foundations, educational institutions,
nonprofit organizations, and businesses. NORC projects in Tribal communities have involved
communications, health disparities, educational attainment, and historical trust fund accounting. NORC
is committed to safeguarding the confidentiality of personal information and survey responses. All
NORC staff, including interviewers, sign a pledge to protect confidential information. Your interviewer
can give you more details about that pledge.
SUPPORT SERVICES INTERNATIONAL, INC. (SSI)
Support Services International, Inc. (SSI) is a Native American-owned firm that has studied the FDPIR
Program, Indian housing, economic development, health, and social services. Its areas of expertise
include program evaluation and policy analysis, policy review, development and analysis, and survey and
evaluation research.
Panel 6: Middle back
Topic: How to reach us…
Urban Institute website - www.urban.org - 202-833-7200
Nancy Pindus: 202-261-5523 - [email protected]
NORC website – www.norc.org
Project toll free number: 888-493-5957
3
Project email: [email protected]
Carol Hafford: 301-634-9491 – [email protected]
SSI website: www.ssinar.com
Walter Hillabrant: 301-587-9006 - [email protected]
Urban Institute ,NORC, and SSI logos will also appear on this page.
4
(USDA/FNS letterhead etc…)
(date)
Dear (tribal leader),
I would like to take this opportunity to build on the Consultations conducted by the United States
Department of Agriculture (USDA) Food and Nutrition Service (FNS) with Tribal Leaders over the past
year and provide you with more information about the Study of the Food Distribution Program on Indian
Reservations (FDPIR). As you know, this important project will be conducted during the summer of 2013
on 26 randomly selected reservations and tribal areas across the country. The Urban Institute, a
nonprofit research organization based in Washington, DC, is leading the study. The Urban Institute will
be assisted by NORC at the University of Chicago, an independent, nonprofit research organization, and
Support Services International, Inc. (SSI), a Native American owned research firm in Silver Spring, MD.
The (name of tribe) was selected at random from among all federally-recognized tribes participating in
the FDPIR program to be part of the in data collection activities for this study. While your participation
in this study is voluntary, I encourage you to participate; through your participation, your community
will help USDA improve food distribution for native families in Indian Country.
This study will provide USDA with information on FDPIR participants and will provide updated
information on local program operations across the nation. The last nationally representative study of
FDPIR participants and programs was completed in 1990. Since then, significant changes have occurred
in the FDPIR program, including changes to eligibility rules, foods offered, and food delivery options.
This study is needed to help FNS identify ways to make the program work better for participants.
There are three phases of data collection:
1. Case record review. NORC staff will review FDPIR case records to collect information about
program participants and their characteristics. The information collected will include household
composition (how many adults and children live there) income sources, and other available
resources or benefits. The case record review will occur with the 25 sampled sites. About 32
records will be reviewed at each of the sites, with a little more at the larger sites. NORC staff will
work with each tribe or ITO to conduct the case review, making sure to respect Tribal
procedures. Since many programs use paper records, the case review will usually involve a visit
to the FDPIR office by researchers to collect participant information from the records. All
information collected from the case record reviews will be carefully protected and participants’
privacy ensured. We will not be collecting any identifying information about FDPIR participants
during the case record review (that is, we will not collect information such as names, address,
phone number, Social Security Number, etc.). Households selected for the case record review
will also be asked to take a survey about the FDPIR program.
2. Survey of participants. We will ask each household that we collect information about from the
case records if they are willing to do a 30-minute interview. On average, 32 interviews will be
conducted per site, with more in the largest programs. It is assumed that most of the interviews
will be conducted by telephone, and the remaining interviews will be in-person. Participants
will receive a letter about the study in advance of being contacted. The letter and materials will
include a toll free phone number for any questions they may have. Each participant will receive
agift card or voucher worth $25. NORC field interviewers will conduct the survey and work
closely with tribal leaders and FDPIR programs.
3. Program Site Visits. Site visits and interviews with tribal leaders, program staff and others
present an opportunity to collect information on the issues that surround food distribution and
families' nutrition needs. On-site visits will be conducted with only 17 of the 26 sites. The site
visits will include three types of activities: (1) interviews with program administrators, staff and
service providers; (2) visits to FDPIR programs to observe facilities related to client enrollment,
warehouses, and food distribution; and (3) discussion groups with program clients and potential
clients. The Urban Institute and SSI will conduct the site visits.
The Urban Institute and NORC will be contacting you soon to find out the proper procedures for
implementing the data collection activities on your (reservation/tribal area).
Please see the enclosed brochure for additional information. Also, please feel free to call or email me
with any questions you may have. (Include email and phone information)
(Signature etc…)
Letter # 2 – FDPIR Directors from Urban/NORC
Dear (FDPIR Director)
As stated in the letter recently sent from (USDA name and title), USDA has contracted with the Urban
Institute, a non-profit policy research organization based in Washington DC, to conduct the Study of the
Food Distribution Program on Indian Reservations (FDPIR).
This study will provide current, nationally representative information on FDPIR participants and will
provide updated information on local program operations across the nation. The last nationally
representative study of FDPIR participants and programs was completed in 1990. Since then, significant
changes have occurred in the FDPIR program, including changes to eligibility rules, foods offered, and
food delivery options. This study is needed to help USDA’s Food and Nutrition Service (FNS) identify
ways to make the program more beneficial to participants.
As part of the study, Urban has partnered with NORC at the University of Chicago, and independent,
non-partisan research organization to work with the sites for a case record review for selecting the
household sample and also to conduct interviews with the selected participants. The other partner is
Support Services International, Inc. (SSI), a Native American owned research firm in Silver Spring, MD.
SSI will be assisting with the program site visits.
The (name of tribe) was selected at random from among all federally-recognized tribes participating in
the FDPIR program to be part of the in data collection activities for this study. We realize there are
special protocols to be followed when conducting studies on tribal lands. We plan to strictly research
and follow these protocols before making any contacts.
The purpose of this letter is to request your participation in separate phases of this important study.
The first is the case record review. The purpose of the case record review is to obtain information that
will describe current program participants and their characteristics. This will include household
composition, income sources, and other available resources or benefits. The case record review will
occur with the 25 sampled sites. About 32 records will be reviewed at the sites, with a little more at the
larger sites. NORC staff will work with each tribe or ITO to conduct the case review, making sure to
respect Tribal procedures. Since many programs use paper records, the case review will usually involve a
visit to the FDPIR office by researchers to abstract participant information from the records. All
information drawn from the case record reviews will be carefully protected and participants’ privacy
ensured. Households selected for the case record review will be part of the survey sample.
The second phase the study is the survey of participants. For each household sampled from the case
records, a 30-minute interview will be conducted. On average, 32 interviews will be conducted per site,
with more in the largest programs. It is assumed that most of the interviews will be conducted by
telephone and the remaining in-person. Participants will receive a letter about the study in advance of
being contacted. The letter and materials will include a toll free number for any questions they may
have. Each participant will receive an incentive worth $25. NORC field interviewers will conduct the
participant survey and work closely with tribal leaders and FDPIR programs to implement the study
procedures.
The third phase is program site visits. Site visits and interviews with tribal leaders, program staff and
others present an opportunity to present richer and more valuable data on the issues that surround
food distribution. On-site visits will be conducted with only 17 of the 25 sites. The site visits will include
three types of activities: (1) interviews with program administrators, staff and service providers; (2) visits
to FDPIR programs to observe facilities related to client enrollment, warehouses, and food distribution;
and (3) discussion groups with program clients and potential clients.
You will be contacted soon by a member of the study staff to answer any questions. In the meantime
please feel free to call us with any questions or concerns you may have.
Sincerely,
Nancy Pindus
Principal Investigator
Urban Institute
Urban Institute website - www.urban.org - 202-833-7200
Nancy Pindus: 202-261-5523 - [email protected]
NORC website – www.norc.org
Project toll free number: 888-493-5957
Project email: [email protected]
Carol Hafford: 301-634-9491 – [email protected]
Letter # 3 – Urban/NORC letter to tribal leaders
Dear (name of tribal leader)
As stated in the letter recently sent from (USDA name and title), USDA has contracted with the Urban
Institute, a non-profit policy research organization based in Washington DC, to conduct the Study of the
Food Distribution Program on Indian Reservations (FDPIR).
This study will provide current, nationally representative information on FDPIR participants and will
provide updated information on local program operations across the nation. The last nationally
representative study of FDPIR participants and programs was completed in 1990. Since then, significant
changes have occurred in the FDPIR program, including changes to eligibility rules, foods offered, and
food delivery options. This study is needed to help USDA’s Food and Nutrition Service (FNS) identify
ways to make the program more beneficial to participants.
As part of the study, Urban has partnered with NORC at the University of Chicago, and independent,
non-partisan research organization to work with the sites for a case record review for selecting the
household sample and also to conduct interviews with the selected participants. The other partner is
Support Services International, Inc. (SSI), a Native American owned research firm in Silver Spring, MD.
SSI will be assisting with the program site visits.
The (name of tribe) was selected at random from among all federally-recognized tribes participating in
the FDPIR program to be part of the in data collection activities for this study. We realize there are
specific protocols for entering and doing the study activities on the reservation/tribal service area and
we fully plan to follow the prescribed protocols before making any contacts. Someone from NORC will
be in contact with your office to inquire about the required procedures that need to be put into place.
The purpose of this letter is to request your participation in two phases of this important study. As
mentioned in the letter from (name and title) there are three phases of the study:
The first is the case record review. The purpose of the case record review is to obtain information that
will describe current program participants and their characteristics. This will include household
composition, income sources, and other available resources or benefits. The case record review will
occur with the 25 sampled sites. About 32 records will be reviewed at the sites, with a little more at the
larger sites. NORC staff will work with each tribe or ITO to conduct the case review, making sure to
respect Tribal procedures. Since many programs use paper records, the case review will usually involve a
visit to the FDPIR office by researchers to abstract participant information from the records. All
information drawn from the case record reviews will be carefully protected and participants’ privacy
ensured. Households selected for the case record review will be part of the survey sample.
The second phase the study is the survey of participants. For each household sampled from the case
records, a 30-minute interview will be conducted. On average, 32 interviews will be conducted per site,
with more in the largest programs. It is assumed that most of the interviews will be conducted by
telephone and the remaining in-person. Participants will receive a letter about the study in advance of
being contacted. The letter and materials will include a toll free number for any questions they may
have. Each participant will receive an incentive worth $25. NORC field interviewers will conduct the
participant survey and work closely with tribal leaders and FDPIR programs to implement the study
procedures.
The third phase is program site visits. Site visits and interviews with tribal leaders, program staff and
others present an opportunity to present richer and more valuable data on the issues that surround
food distribution. On-site visits will be conducted with only 17 of the 25 sites. The site visits will include
three types of activities: (1) interviews with program administrators, staff and service providers; (2) visits
to FDPIR programs to observe facilities related to client enrollment, warehouses, and food distribution;
and (3) discussion groups with program clients and potential clients.
Please be assured that we will follow strict rules to protect your confidentiality. The information
provided in any of the three phases will be combined with information we receive from all others who
are surveyed, and neither anyone’s name nor the tribe, nor any other identifying information will be
passed along to USDA/FNS or others, or cited or reported in any way.
If you have any questions or concerns at this time please feel free to contact us at any time. We look
forward to working with you and your staff on this important undertaking.
Sincerely,
Nancy Pindus
Principal Investigator
Urban Institute
Urban Institute website - www.urban.org - 202-833-7200
Nancy Pindus: 202-261-5523 - [email protected]
NORC website – www.norc.org
Project toll free number: 888-493-5957
Project email: [email protected]
Carol Hafford: 301-634-9491 – [email protected]
Suzanne Bard: 312-759-4255 – [email protected]
(USDA/FNS letterhead etc…)
(date)
Dear (FDPIR Director),
I would like to take this opportunity to build on the Consultations conducted by the United States
Department of Agriculture (USDA) Food and Nutrition Service (FNS) with Tribal Leaders over the past
year and provide you with more information about the Study of the Food Distribution Program on Indian
Reservations (FDPIR). You may have heard about the study or attended the consultations. Please share
this information with your staff.
As you know, this important project will be conducted during the summer of 2013 on 25 randomly
selected reservations and tribal areas across the country. The Urban Institute, a nonprofit research
organization based in Washington, DC, is leading the study and will be assisted by NORC at the
University of Chicago, an independent, nonprofit research organization founded in 1941, and Support
Services International, Inc. (SSI), a Native American owned research firm in Silver Spring, MD.
The (name of tribe) was selected at random from among all federally-recognized tribes participating in
the FDPIR program to be part of the in data collection activities for this study. While your participation
in this study is voluntary, I encourage you to participate; through your participation, your community
helps USDA improve food distribution for native families in Indian Country.
This study will provide current, nationally representative information on FDPIR participants and will
provide updated information on local program operations across the nation. The last nationally
representative study of FDPIR participants and programs was completed in 1990. Since then, significant
changes have occurred in the FDPIR program, including changes to eligibility rules, foods offered, and
food delivery options. This study is needed to help FNS identify ways to make the program more
beneficial to participants.
There are three phases of data collection.
1. Case record review. The purpose of the case record review is to obtain information that will
describe current program participants and their characteristics. This will include household
composition, income sources, and other available resources or benefits. The case record review
will occur with the 26 sampled sites. About 32 records will be reviewed at the sites, with a little
more at the larger sites. NORC staff will work with each tribe or ITO to conduct the case review,
making sure to respect Tribal procedures. Since many programs use paper records, the case
review will usually involve a visit to the FDPIR office by researchers to abstract participant
information from the records. All information drawn from the case record reviews will be
carefully protected and participants’ privacy ensured. Households selected for the case record
review will be part of the survey sample.
2. Survey of participants. For each household sampled from the case records, a 30-minute
interview will be conducted. On average, 32 interviews will be conducted per site, with more in
the largest programs. It is assumed that most of the interviews will be conducted by telephone
and the remaining in-person. Participants will receive a letter about the study in advance of
being contacted. The letter and materials will include a toll free number for any questions they
may have. Each participant will receive an incentive worth $25. NORC field interviewers will
conduct the participant survey and work closely with tribal leaders and FDPIR programs to
implement the study procedures.
3. Program Site Visits. Site visits and interviews with tribal leaders, program staff and others
present an opportunity to present rich contextual information on the issues that surround food
distribution and families' nutrition needs. On-site visits will be conducted with only 17 of the 25
sites. The site visits will include three types of activities: (1) interviews with program
administrators, staff and service providers; (2) visits to FDPIR programs to observe facilities
related to client enrollment, warehouses, and food distribution; and (3) discussion groups with
program clients and potential clients. The Urban Institute and SSI will conduct the site visits.
The Urban Institute and NORC will be contacting you soon to find out the proper protocol for
implementing the data collection activities on your (reservation/tribal area). I know this will do
everything possible to make this effort as burden free as possible for your staff.
Please see the enclosed brochure for additional information. Also, please feel free to call or email me
with any questions you may have. (email and phone information)
(Signature etc…)
# 5 – Letter to respondents
(date)
Dear Sir/Madam,
We are writing to let you know that you have been randomly selected to take part in a very important
national survey of food distributions on native lands and to ask for your help. It is called the Study of the
Food Distribution Program on Indian Reservations (FDPIR). is one of
only 25 selected from across the country to be in this study.
The food distribution study is funded by the U. S. Department of Agriculture (USDA) and is being
conducted by Urban Institute and NORC at the University of Chicago. This study will collect information
about people who are in the FDPIR program and also provide updated information on local program
operations across the nation.
The survey will take about 45 minutes to finish. Some of the topics covered include FDPIR and other
contributions to your food supply, food costs, health and diet concerns, your use of other food
assistance programs, nutrition education, and your overall satisfaction with the food distribution
program.
We have been given approval by your for taking the survey.
Over the next few weeks an interviewer from NORC will be in touch with you about participation in the
survey. The interviewer is prepared to answer any questions you may have. In the meantime please
feel free to call our toll free number with any questions you may have. That number is 800-XXX-XXXX.
Also, please see the enclosed brochure for more information.
Thank you so much for reading this letter and considering our request.
Sincerely,
Signatures and logos
SAMPLE TRIBAL RESOLUTION FOR FDPIR STUDY
Resolution No.__________
RESOLUTION
Number__________
WHEREAS, the [name of tribal council] is the duly constituted governing body within the
boundaries of the Reservation or service area, and
WHEREAS, the [name of tribal council] has been organized to represent, develop, protect and
advance the views, interests, education and resources of the Reservation or service area, and
WHEREAS, Pursuant to the [name of tribe] Tribal Constitution, Article A, Sections 0(x) and
l(y), the [name of tribal council] has the power and authority to manage all economic affairs of
the [name of] Tribe, and
WHEREAS, The U.S. Department of Agriculture Food and Nutrition Services (USDA/FNS) is
conducting a Study of the Food Distribution Program on Indian Reservations (FDPIR) to provide
an updated description of participants and programs, gain a better understanding of why FDPIR
participation, nationally, has been declining, and provide FNS with information necessary to
improve the program.
WHEREAS, the benefits of the study for FNS and [name of tribe] includes identifying the needs
of participants and ways to make the program more beneficial to them, and to provide knowledge
that can be shared among Tribes and Indian Tribal Organizations (ITO); and
WHEREAS, the [name of tribe] has been selected through a nationally representative sample of
all federally-recognized tribes participating in the FDPIR program; and
WHEREAS, USDA/FNS has contracted with the Urban Institute and its partners, NORC at the
University of Chicago, an independent social science research firm, and Support Services
International, to conduct the study; and
WHEREAS, the study includes a case record review that will describe current program
participants and their characteristics, including household composition, income sources, and
benefits, and that it will be necessary for the [name of tribe] to draw a random sample of
households participating in the program using specifications provided by NORC, that NORC
research staff will conduct the abstraction of the information on site at the FDPIR program office,
have direct access to case records that contain personally identifiable information but that no
personally identifiable information will be abstracted about program participants; and
WHEREAS, the study also includes a participant survey involving each household sampled for
the case record review, for which the [name of tribe] will provide a list of names and addresses of
program participants from whom NORC will seek participation in the study and from whom the
designated NORC field interviewer will obtain written or verbal informed consent, and once
consent is obtained will ask the program participant questions about food storage and preparation,
FDPIR contribution to the household’s food supply, access to the FDPIR program and access
barriers, food costs, participation in FDPIR and other food assistance programs, nutrition
education and other health-related services, and satisfaction with the program and will take 45
minutes to complete, for which the respondent will receive a $25 incentive; and
WHEREAS, NORC at the University of Chicago, in accordance with protection of human
subject research and as approved by its federally recognized Institutional Review Board (IRB),
will remove all identifiers from data gathered to protect the anonymity and confidentiality of
[name of tribe] participants; and
WHEREAS, NORC recognizes the sovereignty of the [name of] Tribe and acknowledges that
upon the conclusion of the Federal evaluation, the [name of] Tribe will retain ownership and
control over the data collected within the boundaries of the [name of tribe] Reservation or service
area and will have access to all data collected for their project; and
THEREFORE BE IT RESOLVED, that the [name of Tribal Council] grants permission to
NORC at the University of Chicago to collect data for the case record review and participant
survey for the Study of the Food Distribution Program on Indian Reservations, and further be it
resolved, that upon the conclusion of the Federal study, data collected within the boundaries of
the [name of tribe] Reservation belong to the [name of] Tribe and may not be released in any
form to individuals, agencies, or organizations without additional tribal authorization.
NOW, BE IT FINALLY RESOLVED, that the [name of Tribal Council] authorizes the
Chairman and the Secretary to execute this Resolution.
ATTEST
THE [name of tribe]
____________________________
Name, Title
Name of Tribal Council
__________________________
Name, Title
Name of Tribal Council
CERTIFICATION
I hereby certify that the foregoing resolution was adopted by the [name of Tribal Council] in a duly
called, noticed and convened Special Session assembled for business on the nth day of [month, year] with
XXX (X) members present to constitute a quorum and by a vote of XXX (X) members FOR, ZERO (0)
members OPPOSED and ZERO (0) members abstaining.
___________________________________
Name, Title
Name of Tribal Council
THE URBAN INSTITUTE 2100 M STREET, N.W. / WASHINGTON D.C. 20037
TO:
THRU:
FROM:
DATE:
SUBJ:
Everett Madden, IRB Administrator
Rolf Pendall, METRO Center Director
Nancy Pindus, Principal Investigator
10/10/2012
Request for IRB Review
PD/Project (Name & No.): Study of Food Distribution Programs on Indian Reservations
(08322-20-000)
Type of Review Requested:
1. Initial IRB Review:
[ ] Full Review: attach six copies of materials, or
[ X ] Expedited Review: attach two copies of materials.
or
2. Annual Review or When There Has Been a Change to a Previously Approved Project:
[ ] No changes. I certify that there have been no changes in the following since the last IRB
review: purpose, methods and procedures, including study population and what is required of the
subjects to include —
Potential risks and benefits
Consent procedures to be followed
Data security plan
Survey instrument
[ ] There have been changes in the project since the last IRB review. Provide narrative
summary of changes and attach revised materials, highlighting the changed sections, as
appropriate.
_______________________
PI Signature
_________
Date
_______________________
Center Director Signature
_________
Date
1
Request for Expedited IRB review
STUDY OF FOOD DISTRIBUTION PROGRAMS ON INDIAN RESERVATIONS:
PRETEST OF SURVEY INSTRUMENTS
UI # 08322-020-00
This is a request for an expedited review for pretesting the survey instruments of a 3-year
study of the Food Distribution Programs on Indian Reservations that the Urban Institute is
undertaking between November 2011 and October 2014. The evaluation is being done under
contract to the U.S. Department of Agriculture, Food and Nutrition Service.
The Principal Investigator is Nancy Pindus, the Project Manager is Diane Levy, and
Urban Institute staff includes Doug Wissoker, Chris Narducci, Sophie Litschwartz, and Jennifer
Biess. Subcontractors involved in pretesting will be NORC at the University of Chicago, whose
staff includes Carol Hafford and Suzanne Bard; and Support Services International, Inc., whose
staff includes Walter Hillabrant and Judy Earp.
The pretest will be conducted in 2-3 FDPIR sites. Pretest participants will be recruited by
contacting tribes with whom NORC, UI, or SSI has an established relationship through prior
work. These tribes have indicated a willingness to assist in the pretest process and they are not
part of the sample selected for the study of Food Distribution Programs on Indian Reservations.
While a full IRB review will be requested prior to beginning primary data collection activities
associated with these surveys and interview guides, at this time we are requesting an expedited
IRB review to allow us to pretest the following data collection protocols (see attached table for a
summary of data collection instruments and respondents):
1. Case Record Review Form
NORC will take the lead in testing procedures for accessing case records and extracting data, as
well as pretesting the case record review form itself. We plan to obtain and review 5 case records
at each of the 2-3 FDPIR pretest sites in order to have a small pool from which to select a 2-3
participants to interview in each site (see FDPIR participant survey, below). There are three
possible scenarios for conducting the case record review: (1) electronic data transfers for sites
with electronic records; (2) onsite data abstraction by NORC staff; (3) secure shipment of
unredacted copies of records by the FDPIR program to NORC staff. Our working assumption is
that the majority of FDPIR programs do not have automated case record files. Therefore, the
pretest of the case record review from will be conducted on-site for at least one of the programs.
The preferred method will be discussed with each site and the appropriate data sharing
agreement and procedures will be applied for each situation, as detailed below in the section on
Human Subjects and Data Security Issues.
The Case record Review Form is included in Appendix 1.
2
2. FDPIR Participant Survey
NORC will take the lead in testing this primarily close-ended questionnaire designed to assess
household food needs and satisfaction with the FDPIR program. For the pretest, a total of 8
interviews will be conducted in 2-3 FDPIR sites. Pretest participants will be drawn from the case
records that were reviewed. Pretest respondents will receive an incentive of $25 for their time
and cooperation. Upon completion of the pretest field work, a telephone debriefing session will
take place with the interviewers. A debriefing report will be produced and shared with FNS and
the Urban Institute in order to make revisions to the instrument. The Participant survey pretest
will be audio taped (with the consent of the participant) and audiotapes will be destroyed after
the instruments have been revised and approved by OMB.
The Participant survey instrument is included in Appendix 1.
3. Participant/Eligible Nonparticipant Discussion Group Guide
NORC will take the lead in testing the discussion guide designed for current FDPIR participants
and eligible nonparticipants. The discussion aims to collect information from eligible FDPIR
candidates on how they choose between different food assistance programs and what they think
about the food and related services offered in FDPIR. For the pretest, 2 individuals (FDPIR
participants and/or eligible nonparticipants) will be selected to pretest the discussion guide in an
interview format. The discussion group pretest respondents will receive an incentive of $25 for
their time and cooperation. Pretest participants will be recruited as part of the process for
recruiting for the Participant Survey pretest. The contacts with tribes will also pretest their ability
to identify nonparticipants as well as participants and any concerns they may have about
including nonparticipants and participants in the same group. A debriefing will be held to discuss
the pretest experience, followed by a written report covering any suggested improvements and
suggestions.
The discussion group guide is included in Appendix 3.
4. On-Site Interview Guides
UI will take the lead in testing the semi-structured interviews over the telephone with two Tribal
leaders, two FDPIR representatives, and two representatives of other programs that work with
FDPIR or serve FDPIR participants, such as IHS, WIC, and TANF (a total of 6 interviews).
Pretesters will be UI, NORC, and SSI staff. Pretest participants will be recruited as part of
process described above for the caser record review and participant survey pretest, by contacting
tribes with whom we have an established relationship through prior work. A debriefing will be
held to discuss the pretest experience, followed by a written report covering any suggested
improvements and suggestions.
The on-site interview guides are included in Appendix 4.
3
HUMAN SUBJECTS AND DATA SECURITY ISSUES
This section identifies human subjects and data security issues that pertain to the pretests.
A. Pretest of Case Record Review Procedures and Form
Study populations. The Case Record Form will be will be tested with 5 case records in
each of 2-3 sites. No new data collection will be involved, rather, we will be using the site’s
existing participant case files.
How data will be collected. NORC will extract case file data in one of three ways:
Scenario (1): Electronic data transfers for sites with electronic records. Research
staff will consult with the tribe to establish a secure method of data transfer and the
format of the data. Potential methods include having the program ship the encrypted data
file(s) on an external hard drive to NORC (through a secure and traceable carrier), or
transferring these files to NORC servers using secure FTP. These methods are used for
data transfers in NORC’s Data Enclave, which provides a confidential, protected
environment within which authorized researchers can access sensitive microdata
remotely.
Scenario (2): Onsite data abstraction by NORC staff. For sites that do not have
electronic records we will arrange a site visit. A NORC researcher trained in the data
abstraction procedures will conduct the case record review. Data abstraction will be
conducted manually using a pre-formatted template that has been installed on a secure
NORC laptop computer. NORC staff will conduct the case review in a secure area of the
FDPIR Program’s offices during working hours (typically 8.00 AM to 4.30 PM). It is
advisable to have a member of the FDPIR staff available to answer questions (e.g., to
decipher handwriting on a form).
Scenario (3): Secure shipment of unredacted copies of case records by ITO to
NORC. For very small sites, we will propose that FDPIR staff copy and transmit
unredacted copies of the case records through a secure and traceable carrier; NORC will
cover the cost of copying and shipping. NORC staff will abstract the data to obtain the
necessary data elements and information for contacting potential respondents. This
activity will occur at NORC’s Bethesda, MD office. Per NORC data security procedures,
all paper case records will be locked in secure files and destroyed upon completion of the
abstraction process. Procedures for the secure transfer of paper case records will be
negotiated in the Data Sharing Agreement.
Use of Records Linked to Individuals. We will develop unique identifiers that will link
the information abstracted from each case record to the corresponding respondent for the
Participant Survey. Procedures will be tailored to the circumstances and individual tribal
procedures for accessing data for research purposes. These will be discussed in advance with the
pretest tribes and Data Sharing Agreements will be negotiated. For the pretest, since the number
of records is small and data will not be retained beyond the stage of instrument revision and
OMB clearance, we anticipate the data sharing agreement to be streamlined.
Potential Risks. The information extracted from the case files will include sensitive
4
information, such as household characteristics and composition, and income and employment.
This information could compromise the privacy and integrity of FDPIR participants if shared
with the wrong party. Our data protection plan explains how we will address these potential
risks.
Informed consent procedures. An introductory letter will be sent to pretest respondents
for the participant survey and this letter will also inform respondents that information pertaining
to eligibility and FDPIR participation history will be obtained from their case files. We will
explain that unique identifiers will be assigned that will link the information abstracted from
each case record to the corresponding respondent for the Participant Survey. (See discussion
under Section B, Pretest of Participant Survey and Participant Discussion Group Guide for
further discussion of informed consent procedures).
B. Pretest of Participant Survey and Participant Discussion Group Guide
Study populations. The Participant Survey will be will be tested on 8 individual
households in 2-3 different FDPIR service areas that have not been selected for the study sample.
The group discussion guide will be tested on 2 heads of Tribal households in FDPIR sites that
are not in the sample.
How data will be collected. For both the survey and discussion guide, data collection
will be conducted by staff from NORC and done in-person. Survey interviews will be audiotaped
contingent upon permission of the subject in order to inform question wording and probing.
Notes will also be taken during the survey with paper and pencil. Discussion guide interviews
will involve note taking, but no audio recording. The Data Security Plan discusses how such
records will be handled. Following onsite data collection, a debriefing will occur and a report
produced of the findings from conducting the test.
Use of Records Linked to Individuals. NORC staff will never record identifying
information on the same forms as any forms containing survey data. Respondents will be
assigned code numbers (e.g., “Participant Pretest 1”) and these will be stored separately from the
respondent contact/identifying information. All recorded information will be stored in locked file
cabinets until it is no longer needed. Survey data will never be stored in the same place as
identifying information and survey data will be destroyed after the pretest is complete.
Potential Risks. Much of the information collected in the Participant survey and Group
Discussion will involve sensitive information, such as participants’ health and nutrition and
needs, household characteristics and composition, and income and employment. This survey will
contain sensitive information that could compromise the privacy and integrity of interviewees if
shared with the wrong party. Our data protection plan explains how we will address these
potential risks.
Informed consent procedures. Introductory letters will be sent to survey pretest
respondents and discussion group pretest participants prior to scheduling the interview. See the
introductory scripts to the Survey and Discussion Guide in the following appendices.
Specifically, the study’s informed consent procedures will include the following information:
5
The purpose of the study, who is conducting it, and how the data will be used;
That participation is voluntary;
That the interview will be recorded (with the respondent’s permission);
That respondents can refuse to answer any question and/or quit the survey at any point
without penalty;
That respondents’ privacy will be protected; that the information collected will be
reported without identifying the individual interviewee;
That the identity of all households participating in the study will be kept confidential
from the tribe.
In addition to these informed consent procedures planned for the evaluation, pretest
participants will be informed that their responses on the pretest will NOT be included in the
evaluation and that the information will be destroyed after the pretest. The research team will not
disclose to FNS, or to any others outside of the research staff indicated above, the individuals, or
tribal or program officials that have been selected for the pretest. Nor will we tell respondents
who else was selected for the pretest or who responded.
C. Pretest of in-person interview guides
Interview population. There will be 6 program-related pretest interviews with tribal area
administrators and officials. The guide, which is organized into topic-specific modules, will be
tested on two Tribal leaders, two FDPIR program directors, and two related-service program
directors in FDPIR program sites that are not part of study sample.
How data will be collected. For the pretest of the interview guide, data collection will be
conducted by staff from the Urban Institute and SSI over the telephone. Notes will be taken
during the interview, but it will not be audio recorded. Following the pretest, a debriefing will
occur and a report produced of the findings from conducting the test.
Use of Records Linked to Individuals. Urban Institute and SSI staff will never record
identifying information on the same forms as any forms containing interview data. Respondents
will be assigned code numbers (e.g., “Tribal Interview Pretest 1”) and these will be stored
separately from the respondent contact/identifying information. All recorded information will be
stored in locked file cabinets until it is no longer needed. Interview data will never be stored in
the same place as identifying information and interview data will be destroyed after the pretest is
complete.
Potential Risks. Some of the information collected in the guides will involve sensitive
information, such as perceptions of other federal, state, and local agencies, local populations, and
socioeconomic conditions. These interviews will contain sensitive information that could
compromise the privacy and integrity interviewees if shared with the wrong party.
Informed consent procedures. Introductory letters will be sent to interviewees prior to
scheduling the interview. See the introductory scripts to the guide in Appendix 3. Specifically,
the study’s informed consent procedures will include the following information:
The purpose of the study, who is conducting it, and how the data will be used;
6
That participation is voluntary;
That respondents can refuse to answer any question and/or quit the survey at any point
without penalty;
Taping of interviews will be done only with the permission of the respondent and the
respondent can request that the tape recorder be turned off at any time.
That respondents’ privacy will be protected; that the information collected will be
reported without identifying any individual interviewee.
In addition to these informed consent procedures planned for the evaluation, pretest
participants will be informed that their responses on the pretest will NOT be included in the
evaluation and that the information will be destroyed after the pretest.
7
Pre-test
Instrument
1. Participant
Survey
2. Discussion
group discussion
guide
3. On-site
Interview Guide
for: a) FDPIR
managers and
staff; b) other
service
providers; c)
Tribal leaders
Population
Definition
8 Heads of
tribal
households
within 2-3
FDPIR service
areas that are
NOT part of
study sample.
2 Heads of
tribal
households
within FDPIR
service areas
that are NOT
part of study
sample.
2 Tribal
Leaders; 2
FDPIR Program
Directors; and
2 Other
Program
Directors in
FDPIR program
sites that are
NOT part of
study sample.
Recruitment
The method of
contacting and
selecting the
pretest sites will
follow Tribal
research
protocols. We
have established
relationships and
contacts with
many Tribal
areas nationally
that would be
good candidates
for pre-testing,
as well as a
cohort of AI/AN
interviewers
currently on
NORC staff to
facilitate
pretesting.
Consent
Informed
consent
required of
each pre-test
respondent.
Consent
precedes each
pre-test. See
Instruments
in Appendix
for exact
language.
Method
Interview
of
Incentive
Length
Recording Payments
45
minutes
Audio tape
and
written
notes
$25 cash
or gift card
incentive
1 hour
Written
notes
$25 cash
or gift card
incentive
1.5 hours
Written
notes
No
incentive
Data Security
All written and
recorded information
collected during the
pre-tests will be
subject to the same
data security
procedures described
in the Data Security
Plan section of the IRB
request.
Risk
Much of the information collected
in the Participant survey will
involve sensitive information, such
as participants’ health and
nutrition and needs, household
characteristics and composition,
and income and employment. This
survey will contain sensitive
information that could
compromise the privacy and
integrity of interviewees if shared
with the wrong party.
Some of the information collected
in the guides will involve sensitive
information, such as perceptions of
other federal, state, and local
agencies, local populations, and
socioeconomic conditions. This
information could compromise the
privacy and integrity interviewees
if shared with the wrong party.
8
DATA SECURITY PLAN
This section describes how we will store, handle, report, and dispose of the data collected
through the pretest of the case record review form, participant survey, group discussion guide,
and guides for on-site discussions with program administrators and staff.
Data Identifiers. We will preserve the anonymity of any private persons and entities identified
in the surveys or interviews. Unique case numbers will be assigned to Tribal organizations,
service organizations, and respondents, with respondent identification information kept in a
separate file. The sensitive information will be encoded, burned to CD, and saved in a locked file
cabinet in [name of staff] office until the end of the pretest, at which time all data from the
pretest will be destroyed, as described below. NORC will follow the same procedures for
preserving anonymity of respondents and storing sensitive information.
Data Storage at UI. While the pretest is underway, interview tapes will be uploaded to a
confidential drive on the computer network set up for this purpose and erased from the digital
recorder. Access to the confidential drive will be limited to UI research staff working on the
project who have signed the confidentiality pledge. Hard copies of interview notes will be stored
in a locked file cabinet when not in use. The locked file cabinet will be in Metro and Chris
Narducci, a UI Research Associate will be in possession of the key. Electronic files of interview
notes may also be prepared by researchers by typing notes after interviews. These notes will be
stored on the confidential drive using the assigned identifiers. Hardcopies of any necessary
printouts of sensitive data or electronic media will be kept in locked cabinets in Chris Narducci’s
office. All storage media that hold sensitive data will be marked “CONFIDENTIAL.” Any
printouts of sensitive data that are no longer needed will be shredded. At the end of the pretest,
we will follow the data destruction procedures described below. NORC will follow the same data
storage procedures.
Data Reporting. There will be no data reporting for the pretest. Reporting is limited to a memo
summarizing the pretest experiences and resulting modifications in data collection instruments
and procedures.
Printing. When confidential data are being printed, the pause feature in printing will be
employed so that the printout does not actually print until the sender is present at the printer to
retrieve the copies.
Destruction of other hardcopy documents and electronic media. At the conclusion of the
pretest, hardcopy documents will be shredded and electronic files, including backups, will be
securely deleted using PGP software.
Staff Confidentiality. All Urban Institute staff, NORC staff, and SSI staff will receive training
on the study’s confidentiality procedures. All of these individuals will sign a confidentiality
pledge agreeing not to divulge any information obtained as part of the data collection activities.
A copy of the confidentiality pledge is included as Attachment A.
Since staff of other organizations will also be involved in pretest data collection, additional
procedures will be implemented to assure data security in the sharing of information. NORC and
9
SSI staff will be required to keep their notes and survey documents in a locked file cabinet when
not in use until the summary pretest report is completed. When pretest surveys/interviews are
completed, they will be asked to send all notes to Chris Narducci at the Urban Institute via
FedEx. Electronic copies of notes will be required to be kept secure either on a confidential drive
or a password-protected computer disk. When electronic copies of site reports or any other
material containing site visit information is transmitted to the Urban Institute, a passwordprotected computer disk or CD will be sent to Chris Narducci via FedEx. NORC has its own
institutional IRB and the pretest activities in which NORC staff are involved will require
approval from their IRB as well.
Attachments
Confidentiality Pledge
APPENDICES
1. Participant Survey
2. Group Discussion Guide
3. In-person Interview Guide
10
The Study of Food Distribution Programs on Indian Reservations (FDPIR)
Draft Site Visit Instrument Package
STAFF CONFIDENTIALITY PLEDGE
Study of Food Distribution Programs on Indian Reservations (FDPIR)
Assurance of Confidentiality
The Urban Institute assures all respondents and participating organizations that the
information they release to this study will be held in the strictest confidence by the contracting
organization, and that no information obtained in the course of this study will be disclosed in
such a way as to identify individuals or organizations. Access to the data in this study is by
consent of the respondents who have been guaranteed confidentiality, except when the intent to
commit a crime or harm themselves is revealed to the researcher. Their right to privacy is
protected under law.
I have carefully read and understand this assurance that pertains to the confidential
nature of all information and records to be handled in this study. I have read a copy of the
Confidential Data at the Urban Institute – Guidelines for Data Security. I understand that I must
comply with all of data security requirements adapted from those Guidelines for this project as
approved by the Urban Institute Institutional Review Board. As an employee of, or consultant
to, the Urban Institute, I understand that I am prohibited from disclosing any such confidential
information that has been obtained under the terms of this contract to anyone other than
authorized contractor staff and, if I am an Urban Institute employee, I agree to follow the
procedures outlined to me during training. I understand that any willful and knowing disclosure
of information released to this study may subject an Urban Institute employee to disciplinary
action, up to and including termination of employment.
______________________
(Print Your Name)
______________________________
(Signature)
_____________________________________
(Date)
_____________________________________
(Witness signature)
______________________________________
(Date)
11
The Study of Food Distribution Programs on Indian Reservations (FDPIR)
Draft Site Visit Instrument Package
APPENDICES
Appendix 1 - Household Survey
Appendix 2 - Group Discussion Guide
Appendix 3 - In-person Interview Guide
.
12
6954 FDPIR: Non-Receipt and Receipt of Identifiable Private Information for Study Components
A random sample will be drawn using the Household Issuance History report maintained electronically
by each tribe/ITO. Each tribe will draw the sample using the specifications provided by NORC. The
sample drawn for the case record review and the participant survey uses the same sample frame and
will result in the same set of respondents:
For the Case Record Review the tribe/ITO will draw the sample from the Household Issuance
History. The case files will be pulled from the programs files prior to NORC’s on-site visit and be
available for review.
Using the sample drawn for the Case Record review, the tribe will provide NORC with a list of
names and addresses in order to establish contact with subjects for the Participant Survey.
Sampling Frame is Household Issuance History Report maintained by
Tribe/ITO that reflects current program participants for reference month.
NORC provides guidance to Tribes/ITOs to draw the sample from the
Household Issuance History report.
Using the Household Issuance History report, the
Tribe/ITO pulls a random sample of 32 subjects for the
Case Record Review and Participant Survey.
Case Record Review
Participant Survey
Tribe/ITO makes paper case files
available onsite for NORC review
(Bethesda-team). NORC staff
abstract non-personally
identifiable data [see 4.2.3.a].
Tribe/ITO provides NORC (Chicago
team) with a list of names and
addresses in order to establish
contact with subjects for the
Participant Survey [see 4.2.3.b].
Data are used to develop a
demographic and economic
profile of Program Participants
[see 4.2.2.a and 5.1].
Survey data are used to prepare
descriptive findings on survey
topics [see 5.1].
FDPIR Survey updated 9/10/11
INTERVIEWER: BEFORE STARTING INTERVIEW PLEASE ENTER AVAILABLE AIS DATA IN QUESTION E1.
FDPIR Participant Survey
INTERVIEWER READ: “Hello, my name is [name of interviewer] from NORC at the University of
Chicago. [IF IN PERSON - SHOW NORC ID CARD.] I am (calling/here) about the Study of the Food
Distribution Program on Indian Reservations. Have you by any chance received our letter? It tells
about the study and also mentions you will receive (cash/gift card).
IF YES: Do you have any questions about the survey? May I tell you more about the survey?
IF NO: IN PERSON: Here is a copy of the letter and some information about the project. Should I
leave the materials and come back or call at a later time or could I answer any questions you may
have at this time?
IF NO: TELEPHONE: I can read the letter to you and also send you another copy and some additional
materials in the mail.
INFORMED CONSENT
As you may have learned from the [ADVANCE LETTER SENT/MATERIALS SHARED/TRIBAL
LETTER/COMMUNITY PRESENTATION HELD], this survey is being done to help understand the food
needs of American Indian and Alaska Native families. It is sponsored by the Department of
Agriculture, Food and Nutrition Service.
Your participation is very important to the success of this survey. This survey is voluntary, which
means that you don’t have to take the survey if you don’t want to, and you can decide not to answer
any specific questions. You also may end the interview at any point. You will receive a [CASH GIFT/
GIFT CARD/VOUCHER] as a thank you for taking the survey. The interview will take about 45
minutes.
The information you provide will be confidential, and will not be shared with anyone except for
research staff working on the study. This includes anything that can identify you such as your name,
address, or telephone number. Everyone who works on this survey has signed a legal document
stating they will not reveal any of your personal information and can be severely penalized if they do.
A report will be shared with the tribe/native village at a later date. It will summarize the findings,
without giving names or other information that would identify you or the tribe/native village.
The survey will ask you about the members of your household, (FDPIR/name of program)
contribution to your food supply, the distribution and delivery of the FDPIR food packages, your food
access and costs, any nutrition and health related services available, switching between SNAP and
FDPIR and your satisfaction with the FDPIR program.
The information you provide will be helpful to improve food services in your community and other
communities in Indian Country.
If you have questions about your rights as a survey participant, please call the IRB Human Subjects
Protection hotline, toll-free, at (866) 309-0542. You may also email [insert name here]@norc.org or
visit www.norc.org.
1
FDPIR Survey updated 9/10/11
INFORMED CONSENT FOR USE OF PROXY
Step 1. If respondent declines to participate in the interview but requests that another person responds
to the questions on his/her behalf: 1
For in-person interview:
I have chosen not to participate in the interview but would like [name of person] to answer the
survey questions for me.
Request signature if the interview is conducted in person:
Respondent Name: _____________________________________________________________
Signature: __________________________________________________________
For telephone interview:
You stated that “I have chosen not to participate in the interview but would like [name of person] to
answer the survey questions for me.” Is this correct?
IF YES, I will note your agreement and obtain informed consent from [name of person].
Respondent Name: _____________________________________________________________
IF NO, Thank you for your time. [Terminate interview.]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Step 2. To consent the person who will respond on the respondents’ behalf:
[Name of respondent’s] has declined to participate in the interview and requests that you answer
questions about [his/her]FDPIR participation. Would you be able to answer questions on his/her
behalf?
IF YES, I will need to request your informed consent to answer the survey questions.
IF NO, Thank you for your time. [Terminate interview.]
As you may have learned from the [ADVANCE LETTER SENT/MATERIALS SHARED/TRIBAL
LETTER/COMMUNITY PRESENTATION HELD], this survey is conducted to help understand the food
We anticipate that there will be instances where an elder wishes that another person (e.g., adult child,
grandchild) speaks on his/her behalf about participation in the program.
1
2
FDPIR Survey updated 9/10/11
needs of American Indian and Alaska Native families. It is sponsored by the Department of
Agriculture, Food and Nutrition Service.
Your participation is very important to the success of this survey. This survey is voluntary, which
means that you don’t have to participate and you can decide not to answer any specific questions.
You also may end the interview at any point. You will receive a [CASH GIFT/ GIFT CARD/VOUCHER]
as a token of appreciation for participating in the survey. The interview will take about 45 minutes.
The information you provide will be confidential, and will not be shared with anyone except for
research staff working on the study. This includes anything that can identify you such as the
[respondent’s] name, address, or telephone number. Everyone who works on this survey has signed a
legal document stating they will not reveal any of his/her personal information and can be severely
penalized if they do. A report will be shared with the tribe/native village at a later date. It will
summarize the findings, without giving names or other information that would identify him/her or
the tribe/native village.
The survey will ask about the members of [his/her] household, (FDPIR/name of program)
contribution to [his/her] food supply, the distribution and delivery of the FDPIR food packages,
[his/her] food access and costs, any nutrition and health related services available, switching
between SNAP and FDPIR and [his/her] satisfaction with the FDPIR program.
The information you provide on [respondent’s name behalf] will be helpful to improve food services
in [his/her] community and other communities in Indian Country.
If you have questions about your rights as a survey participant, please call the IRB Human Subjects
Protection hotline, toll-free, at (866) 309-0542. You may also email @norc.org or visit www.norc.org.
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
3
FDPIR Survey updated 9/10/11
USE OF PROXY
(Name of Respondent) has given permission for you to act as a proxy for him/her and answer
questions for the Food Distribution Program on Indian Reservations. The interview will take
approximately 45 minutes). Remember you are answering the questions for (name of respondent)
and not as you would answer them for yourself. I will remind you of that again during the
interview. Do you have any questions? Is now a good time to start?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
4
FDPIR Survey updated 9/10/11
PERMISSION TO BEGIN INTERVIEW
Do I have your permission to begin the interview?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time informed consent obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Informed consent obtained by ___________________________________________
Name of Field Interviewer
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to come back?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
What is the reason you prefer not doing the interview?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5
FDPIR Survey updated 9/10/11
USE OF TRANSLATOR
(Name of Respondent) has given permission for you to act as a proxy for him/her and answer
questions for the Food Distribution Program on Indian Reservations. The interview will take
approximately 45 minutes). Remember you are answering the questions for (name of respondent)
and not as you would answer them for yourself. I will remind you of that again during the
interview. Do you have any questions? Is now a good time to start?
IF YES, Let’s begin. [Certain tribes may require written consent]
Date and time permission obtained:
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
Name of Proxy: _____________________________________________________________
Signature of Proxy __________________________________________________________
IF NO, ASK:
Are there any questions I can answer for you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
When is a good time to do the interview?
Date: ____/____/________
Time: ____:____ ____
AM/PM (circle)
6
FDPIR Survey updated 9/10/11
Time began: __:____
HOUSEHOLD ENUMERATION
INTERVIEWERS: COMPLETE THE HOUSEHOLD ROSTER ON THE NEXT PAGE BY ASKING EACH OF THE QUESTIONS LISTED BELOW FOR
EACH SECTION.
1
Please tell me the names of all persons who live in your household starting with you – the FDPIR applicant. Just tell me their first names. Let’s start with you.
…Do you have a spouse living in the household?
...any children?
…any grandchildren?
…any relatives?
…anyone that is not related to you?
…anyone else that you have not mentioned?
I have listed…(read names from grid)…Have I missed…any babies or small children?
…anyone who usually lives with you but is away now traveling, at school, or in the hospital?
…any lodgers, boarders, or persons you employ who live with you?
…anyone who is part of the household but is away on full-time active duty with the Armed Forces?
…anyone else staying with you?
2
3
4
5
6
7
8
9
10
11
IF RESPONDENT SAYS ‘YES’ TO ANY OF THE CATEGORIES ADD THAT PERSON(S) TO THE LIST ON THE GRID.
Now we would like to ask how each person is related to you. Let’s start with (name of first person), how is he/she related to you?
ASK OR VERIFY GENDER OF EACH PERSON LISTED.
How old were (you/person) on your/his/her last birthday?
FOR EACH PERSON 18 YEARS AND OLDER ASK: What is (your/person’s) marital status. Is he/she married, never married, separated, widowed or divorced?
FOR EACH PERSON ASK: What is the highest year of education (you/person) has completed?
FOR EACH PERSON ASK: Are you/person currently a student?
FOR EACH PERSON OVER 18: Are you/person currently employed? IF YES: Are you/person (READ CATEGORIES ON CHART) CODE EMPLOYMENT STATUS FOR EACH
PERSON. IF WORKING: How many hours per week do you/does person work?
Does anyone in the household receive Social Security, SSI, LIHEAP, TANF or unemployment benefits? IF YES: Who and what do they receive?
Does anyone in the household have access to the internet? IF YES: Who?
Does anyone in the household own or lease a vehicle? IF YES: Who
7
FDPIR Survey updated 9/10/11
HOUSEHOLD ENUMERATION
STATUS
8.
EMPLOYMENT
STATUS
Student ENTER Yes/√
8a.
Hours
per
Week
9.
Other
Benefits
11.
OWN/LEASE
VEHICLE
MARITAL
7..
10.
IINTERNET
ACCESS
5.
6.
EDUCATION
4. AGE
3. GENDER
NAMES OF HOUSEHOLD
MEMBERS
2. REL TO
APPLICANT
Person #
1.
YES/√
YES/√
SELF
01
02
03
04
05
06
07
08
09
10
11
12
a. Spouse
B. Partner
c. Son/Daughter
d. Step-child
e. Foster child
f. Mother
g. Step mother
h. Foster mother
i. Father
j. Step-father
k. Foster father
l. Brother/sister
m. Grandparent
n. Uncle/aunt
o. Cousin
p. Nephew/niece
q. Father-in-law
r. Mother-in-law
s. Bro/sis-in-law
t. Other-in-law
u. Other non-relative
Married (M)
Never married (NM)
Separated (S)
Divorced (D)
Widowed (W)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Less than high school
Some high school, no diploma
High school diploma
Technical school
Trade apprentice
Some college, no diploma
Collage degree
Graduate or professional studies after
collage
Graduate degree
Don’t know
9. Refused
a.
b.
c.
d.
e.
Not working
Working full time
Working part time
In school
Cannot work –
disabled
f.
Job training
g.
TANF approved work
activity
h. Something else
(SPECIFY)
a. SS
b. LIHEAP
c. TANF
d. Unemp.
e. SSI
8
FDPIR Survey updated 9/10/11
Section A: Participant and Household Characteristics
The first section of the interview will help us better understand the characteristics of FDPIR participants and their
households. We’ll begin by talking about where you live, what kind of resources you have in your home for
preparing and storing food and who prepares food.
A1
First, do you live within or off the reservation/ pueblo/
On/Within
Rancheria/ Alaska native village/ tribal service area?
Off
A2
SOURCE: Household Survey, Assessment of Native American,
Alaska Native, and Native Hawaiian Housing Needs (NAHSG)
(HUD/PD&R) [Objective 1.9]
Which of the following equipment or methods of food storage
and preparations do you use in your home . . .
A3
Gas/electric stove
Gas/electric oven
Wood stove
Microwave
Hotplate
Open fire
Refrigerator
Freezer
Root cellar
Ice house
Food canning
Food drying/dehydrator
Other….(SPECIFY)
SOURCE: Bell-Sheeter 2004, Food Sovereignty Assessment Tool
[Objective 1.10]
Who in your household has the major responsibility for
preparing meals?
(REFER TO HOUSEHOLD ENUMERATION, COLUMN 1, FOR
PERSON #)
Does (name of person) feel adequately prepared to cook the
food provided by FDPIR?
SOURCE: Project-developed question and response set.
A4
What is your main source of water for preparing meals? Is it…
● Public or private water system
● Individual well
●Spring
● Cistern
● Stream or lake
●Commercial bottled water
● Other (SPECIFY)?
Gas/Electric stove
Gas/electric oven
Wood stove
Microwave
Hotplate
Open fire
Refrigerator
Freezer
Root cellar
Ice house
Food canning
Food drying/dehydrator
Other SPECIFY): ______________
Person # ___
Yes
No
Don’t Know
Refused
Public or private water system
(includes city water)
Individual well
Spring
Cistern
Stream or lake
Commercial bottled water
Other (SPECIFY):
________________________
9
FDPIR Survey updated 9/10/11
A5.
Now I’d like to ask you some questions about the kinds of health
care services and insurance coverage used by members of your
household. Do you or your family receive any medical services
on the reservation/pueblo/Rancheria/Alaska native village/tribal
service area?
Yes
No
Don’t Know
Refused
IF YES: What are the sources of these services? (HAND
SHOWCARD X TO RESPONDENT) MARK ALL THAT APPLY
Tribal or IHS Health Center or
Clinic
Urban Indian Health Center
Tribally-managed or IHS Hospital
Tribal or IHS Mobile Clinic or Lab
(van)
Home visits (by a physician or
visiting nurse)
Traditional Healers
Community Health Representative
Wellness Center
Emergency Medical Services
Tele-health services
County/Local Health Center
County/Local Hospital
Managed Care Organization
Private doctor’s office
Local Public Health Department
Other (SPECIFY):
SOURCE: Project-developed question. Response categories
based on content analysis of Indian Health Service regions and
tribally-managed health services. [Objective 1.4]
10
FDPIR Survey updated 9/10/11
A6
A7
The next questions are about the types of health care plans and
what sources are available for medical care. Is anyone in the
household covered by health insurance or some other kind of
health care plan?
IF YES, ASK ABOUT EACH PERSON IN HOUSEHOLD.
Is anyone covered by:
1. Private Health Insurance
2. Medicare
3. Medicaid
4. Military Health Care (TRICARE, VA, and others)
5. State Sponsored Health Plan
6. Other Government Program
7. Single Service (E.G., dental, vision, prescriptions)
8. No coverage of any type
9. SCHIP – State Children’s Health Insurance Program
10. Other (SPECIFY):
11. DON”T KNOW
12. REFUSED
1. □ Yes
□ No
2. □ Yes
□ No
3. □ Yes
□ No
4. □ Yes
□ No
5. □ Yes
□ No
6. □ Yes
□ No
7. □ Yes
□ No
8. □ Yes
□ No
9. □ Yes
□ No
10. □ Yes
□ No
11. □ DON’T KNOW
12. □ REFUSED
Yes
No
Don’t Know
Refused
SOURCE: NHANES HEALTH INSURANCE QUESTIONNAIRE (HIQ)
[Objective 1.4]
I’m going to read you a list of common health problems. Does
anyone in your household currently have any of the following
health problems?
INTERVIEWER: IF ‘YES’ TO ANY CATEGORY (A8a THROUGH A8j)
ASK QUESTION AND ENTER # IN SPACE PROVIDED :
How many household members experience (name of category)?
A7a. High blood pressure …………………………………………………
A7b. Diabetes (sugar) ……………………………………………………….
A7c. Overweight/obesity ………………………………………………….
A7d. Heart disease …………………………………………………………
Yes #: ____
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
11
FDPIR Survey updated 9/10/11
A7e. Cancer ……………………………………………………………………
A7f. Underweight …………………………………………………………….
A7g. Liver disease …………………………………………………………..
A7h. Gastro-intestinal problems (e.g., Irritable Bowel
Syndrome, ulcers, lactose intolerance, diarrhea)
………………………………………………………………………..
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes #: ___
No
Don’t Know
Refused
Yes (ASK A8a)
No
Don’t Know
Refused
Low salt #:___
Low sugar #: ___
Low fat #: ___
Lactose intolerant #: ___
Gluten intolerant #: ___
High protein #: ___
Food allergies #: ___
Other (SPECIFY): ______________
#: ___
A7i. Vitamin or mineral deficiencies or anemia ……………….
A7j. Other (SPECIFY)_______________..............................
A8
SOURCE: Based on Usher et al, 1990. [Objective 1.11]
Are there food items you or anyone in your household cannot or
should not eat? These could include foods that cause food
allergies, and foods needed for special diets and the like.
A8a) IF YES - What are they? (CODE ALL THAT APPLY) FOR
EACH RESPONSE ASK: How many persons in your household
have this restriction?
SOURCE: Project-developed question and response set.
[Objective 1.11]
12
FDPIR Survey updated 9/10/11
A9
A10
Now we’re going to change topics and talk about your housing
and utility expenses. Can you tell me whether you are buying
your home, own your home, renting, live rent-free or have some
other arrangement?
SOURCE: Usher et al, 1990 FDPIR Survey [Objective 1.9]
HAND SHOWCARD X TO RESPONDENT
Now I would like to ask about your rent or mortgage payments.
Do not include utilities. Please look at this card and show me
the amount you pay for your rent or mortgage each month. You
can just give me the letter if you prefer.
A11
SOURCE: Project-developed question and response set.
[Objective 1.9]
Now I would like to ask you about the amount you pay for
utilities each month. Please think about the total amount you
pay for gas, electricity, water, trash collection and telephone.
Look at this card and tell me how much you pay for utilities.
What utilities/services are included in that amount?
Own home
Renting
Other (SPECIFY): ______________
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
Less than $100
$100 to $199
$200 to $249
$250 to $299
$300 to $349
$350 to $399
$400 to $449
$450 to $499
$500 to $599
$600 to $699
$700 to $799
$800 to $999
$1,000 to $1,249
$1,250 to $1,499
$1,500 to $1,999
$1,500 to $1,999
$2,500 or more
No cash paid for rent/mortgage
Don’t know
Refused
A.
B.
C.
D.
E.
F.
G.
H.
Less than $100
$100 to $199
$200 to $249
$250 to $299
$300 to $349
$350 to $399
$400 to $449
$450 to $499
Gas
Electricity
Water
Trash collection
Telephone
Other (SPECIFY) __________
13
FDPIR Survey updated 9/10/11
Section B: FDPIR Contribution to Food Supply
These next questions are about the food eaten in your household in the last 12 months, since (current
month) of last year and whether you were able to afford the food you need.
B1
I am going to read you two statements and would like to know if
during the past 12 months, that would be from (month/year), if
these were often true for your household, sometimes true, or
never true for your household.
B1a. The first statement is, “The food that (I/we) bought just 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 last 12
months?
Often true
Sometimes true
Never true
Don’t Know
Refused
B1b. “(I/we) couldn’t afford to eat balanced, nutritious meals.”
Was that often, sometimes or never true for (you/your household)
in the last 12 months?
Often true
Sometimes true
Never true
Don’t Know
Refused
Yes
No (SKIP TO B1c1)
Don’t Know (SKIP TO B1c1)
Refused
Almost every month
Some months but not every
month
Only 1 or 2 months
Don’t Know
Refused
B1d. In the last 12 months, did you ever eat less than you felt you
should because there wasn’t enough money for food?
Yes
No
Don’t Know
Refused
B1e. In the last 12 months, were you/other adults in your
household ever hungry but didn’t eat because there wasn’t
enough money for food?
Yes
No
Don’t Know
Refused
B1c. In the last 12 months, since last (CURRENT MONTH), did
(you/you or other adults your household) ever cut the size of your
meals or skip meals because there wasn’t enough money for food?
B1c1. IF YES ABOVE, ASK How often did this happen –
almost every month, some months but not every month,
or in only 1 or 2 months?
SOURCE (B1a-e): US Household Food Security Survey Module:
Six-Item Short Form[HH3, HH4, AD1, AD1a, AD2, AD3]
14
FDPIR Survey updated 9/10/11
B2
How did you learn about FDPIR? (RECORD VERBATIM and CODE
ANSWER)
B3
SOURCE: Project-developed question and response set.
[Objective 5.1]
Is FDPIR the only or primary source of food for this household?
B3a. Thinking of the other sources of food for this
household, what percentage comes from:
(READ CATEGORIES BELOW AND HAND RESPONDENT
SHOWCARD X).
FDPIR
Other food programs to include, for example,
National School Lunch Program, WIC, Meals on
Wheels
Extended family or tribal community
Grocery/supermarket/convenience store
Traditional/native food sources (hunting, fishing,
berry picking, ricing, gardening, farming)
Food pantries or food banks
Take-out or convenience stores
Other (SPECIFY)
Prior receipt of FDPIR foods by
household
Word of mouth (family, friend)
Referral from tribal social service
program (SPECIFY):
___________
Tribal newsletter or brochure
Outreach by FDPIR staff
(SPECIFY): _________________
Referral from county social
services
Other (SPECIFY): ____________
Yes only source of food (SKIP TO
SECTION C)
No there are other sources (ASK
B3a)
Don’t Know
Refused
____% FDPIR
____% Other Food programs
____% Extended family or tribal
community
____% Grocery/ supermarket/
convenience store
____% Traditional/native food
sources
____% Food pantries/food banks
____% Take-out
____% Other (SPECIFY): __________
INTERVIEWER: INDICATE THE PERCENTAGES OF EACH. THE TOTAL
SHOULD ADD UP TO NEAR 100%.
SOURCE: Project-developed question and response set.
[Objective 2.1, 2.3]
15
FDPIR Survey updated 9/10/11
B4
Is anyone in your household receiving benefits from or
participating in food programs other than FDPIR? Examples would
include (READ CATEGORIES BELOW AND HAND RESPONDENT
SHOWCARD X).
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food Program
Summer Feeding Program or the Summer Food Service
Program
Elderly Meals/Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local programs, other tribal programs
WIC Farmers’ Market Nutrition Program
Seniors Farmers’ Market Nutrition Program
Soup Kitchens
Any others
B4a. IF YES: Which ones?
Yes
No
Don’t Know
Refused
□
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food
Program
Summer Feeding Program or the
Summer Food Service Program
Elderly Meals/ Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local
programs, other tribal programs
WIC Farmers’ Market Nutrition
Program
Seniors Farmers’ Market
Nutrition Program
Soup Kitchens
Other programs(SPECIFY):
_____________________
B5
SOURCE: National Survey of WIC Participants and Their Local
Agencies, Section E Household Income and Food Spending with
some project developed items. [Objective 2.2]
Has anyone in your household referred to other food programs by
the FDPIR staff? Examples would include (READ CATEGORIES
BELOW AND HAND RESPONDENT SHOWCARD X).
Yes (ASK B5a)
No (SKIP TO B6)
Don’t Know
Refused
□
□
Head Start (CACFP)
School Breakfast Program
National School Lunch Program
Child and Adult Care Food Program
Summer Feeding Program or the
Summer Food Service Program
Elderly Meals/ Feeding Programs
Local Food Banks or Pantries
Tribal Emergency Funds
Meals on Wheels
Other state, county, local programs,
other tribal programs
WIC Farmers’ Market Nutrition
Program
Seniors Farmers’ Market Nutrition
Program
Soup Kitchens
Other programs(SPECIFY):
B5a. IF YES: Which programs?
_____________________
16
FDPIR Survey updated 9/10/11
B6
Yes
No
Don’t know
Refused
None
Some
About half
Most
During the past month did you or anyone in your household get
any meals that were prepared by extended family or prepared by a
community group?
□
□
□
Yes
No
Don’t Know
Refused
B7A. IF YES: How often did the household eat meals
prepared by extended family or prepared by a community
group? Would you say none, some, about half or most
meals?
None
Some
About half
Most
I am going to ask you about the sources of meals for your
household. By meals I mean breakfast, lunch and dinner. During
the past month did you or anyone in your household get any meals
that were prepared away from home in places such as restaurants,
fast food places, food stands, grocery stores, or from vending
machines? Do not include meals prepared by extended family or in
a community setting.
B6a. IF YES: About how often did the household eat
meals prepared by such places as restaurants, fast food
places, food stands, grocery stores, or from vending
machines? Would you say none, some, about half, or
most?
SOURCE: National Health and Nutrition Examination Survey
(NHANES) [Objective 2.1]
B7
SOURCE: Project-developed question and response set.
[Objective 2.1]
17
FDPIR Survey updated 9/10/11
Section C: Access to FDPIR - Distribution and Delivery
The next set of questions covers access to the Food Distribution Program in terms of the distance and
time it takes to travel to sites for enrollment, certification, and picking up the food package. There are
also a few questions on the time spent and distances traveled for other sources of food.
C1
When you applied for the FDPIR program approximately how many miles
did you have to travel to the certification site?
C1a. About how long did it take to get there?
___ HRS
C1b. What kind of transportation did you use? Was it your own car
or truck, someone else drove you, you walked, took public
transportation, taxi or some other way?
1. Own car or truck
2. Someone else drove
SPECIFY:
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY: ________________
SOURCE: Project-developed question and response set. [Objective 1.7]
C2
___ Miles
INTERVIEWER: IF THE ANSWER TO C2 IS AVAILABLE PLEASE FILL IN BEFORE
INTERVIEW AND DO NOT ASK THIS QUESTION.
What is your current period of certification? Are you required to recertify
every 1-2 months, every 3-5 months, every 6-11 months or more than a
year?
SOURCE: Project-developed question and response set. [Objective 1.2]
C3
___ MINS
Different places offer several options for getting/picking up the food
package. These options include pickup at FDPIR site, FDPIR store/nutrition
centers, different warehouse location, tailgate location, and home delivery.
Which option do you usually use when getting your food package?
C3a. Are you satisfied with this method?
IF NO: What would you prefer? (RECORD VERBATIM and CODE
ANSWER)
1-2 months
3-5 months
6-11 months
Year or more
Other (SPECIFY)
Don’t know
FDPIR Site
FDPIR Store/Nutrition
Center
Different Warehouse
location
Tailgate Location
Home Delivery (SKIP TO
D1)
Other (SPECIFY):______
_______________________
Yes
No
Don’t Know
Refused
SOURCE: Project-developed question and response set. [Objective 9.1]
18
FDPIR Survey updated 9/10/11
C4
Thinking about picking up your food packages, approximately how many
miles do you have to travel to pick up the food packages?
___ Miles
C4a. About how long does it usually take to get there?
___ HRS
C4b. What kind of transportation do you usually use? Is it your
own car or truck, someone else drove you, you walked, took public
transportation, taxi or some other way?
1. Own car or truck
2. Someone else drove
SPECIFY: ________________
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY: ________________
SOURCE: Project-developed question and response set. [Objective 1.7]
C5
Do you have an authorized representative pick up your food packages?
Yes
No
Don’t Know
Refused
C5a. IF YES: Approximately how many miles does the
representative travel to pick up the food packages?
___ Miles
C5b. About how long does it usually take your representative to get
there?
___ HRS
C5c. What kind of transportation does he/she use? Is it their own
car or truck, they walked, took public transportation, taxi or some
other means of transportation?
SOURCE: Project-developed question and response set. [Objective 1.7]
C6
Does traveling to the FDPIR site present any challenges or problems for
you?
[Objective 4.4]
SOURCE: Project-developed question and response set. [Objective 1.7]
___ MINS
1. Own car or truck
2. Someone else drove
SPECIFY: ________________
3. Walked
4. Public transportation
5. Taxi
6. Some other way
SPECIFY:________________
Yes
No (SKIP TO C7)
Don’t Know
Refused
Yes
No
Don’t Know
Refused
C6a. IF YES, please describe why this is challenging (SPECIFY).
C6b. Is home delivery an option that is offered by the FDPIR
program?
___ MINS
19
FDPIR Survey updated 9/10/11
Section D: Food Access and Cost – Non-subsidized Sources
We are also interested in finding out how easy or hard it is to obtain food in your area and about food
costs.
D1
We are also interested in the distance of other food outlets/suppliers/sources
than FDPIR from your home. Approximately how many miles is the nearest
(CATEGORY) and what is the travel time to get there?
D1a. Nearest food retail store that sells fresh produce ……………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1b. Nearest grocery store………………………………………………………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1c. Nearest convenience store……………………………………………………………………….
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1c. Nearest farmers market………………………………………………………………………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1d. Nearest warehouse store or department store such as Target……………………
____Miles
___ Hrs/Mins
Don’t Know
Refused
D1e. Nearest Wal-Mart that sells groceries…………………………………………………………
D2
Thinking about the past year, that would be from about , have
there been any changes in your access to food sources. Examples of changes
could be opening or closing of supermarkets, changes in food programs and the
like.
____Miles
___ Hrs/Mins
Don’t Know
Refused
Yes (ASK D2a)
No (SKIP TO D3)
Don’t Know
Refused
D2a. IF YES: What are these changes? (RECORD VERBATIM)
SOURCE: Project-developed question and response set.
20
FDPIR Survey updated 9/10/11
D3
On average, what does your household spend each month on food (including
food consumed at home and food consumed outside the home)?
$_____
D3a. Are there seasons when your household spends considerably less
on food expenses?
D3b. Which seasons?
SEASON: ___________
SEASON: ____________
D3c. Why is that? RECORD VERBATIM:
Yes
No (SKIP TO D4)
Don’t Know
Refused
___________________________________________________________
D3d. Are there seasons when you household spends considerable more
on food expenses? (IF NO, SKIP TO SECTION E)
D3e. Which seasons?
Yes
No (SKIP TO
SECTION E)
Don’t Know
Refused
SEASON: ___________
SEASON: ____________
D3f. Why is that? RECORD VERBATIM
SOURCE: Project-developed question and response set.
21
FDPIR Survey updated 9/10/11
Section E: Participation in FDPIR and SNAP/Food Stamps
The next few questions will be about whether your household has also participated in SNAP/Food Stamp
program as well as FDP, if you have ever switched between the two programs, and your reasons for
doing so.
E1
INTERVIEWER: IF AVAILABLE ENTER THE MONTHS OF PARTICIPATION INFORMATION FROM AIS IN THE
CHART BELOW.
IF ALL MONTHS ARE FILLED IN FOR FDPIR/SNAP: SKIP TO QE5.
IF THERE ARE MONTHS WHERE THERE ARE GAPS IN PARTICIPATION FOR FDPIR/SNAP: SKIP TO QE2.
IF AIS INFORMATION IS NOT AVAILABLE: CONTINUE BELOW.
INTERVIEWER: ON THE FIRST LINE UNDER MONTH IN THE CHART BELOW ENTER THE NEXT MONTH FROM
THE INTERVIEW. (IF YOU ARE CONDUCTING THE INTERVIEW IN MARCH – ENTER APRIL). CONTINUE TO FILL
IN THE MONTHS. THE LAST MONTH ENTERED WILL BE THE CURRENT MONTH. THEN ENTER THE YEAR THAT
CORRESPONDS TO EACH MONTH TO SHOW THE LAST YEAR UP UNTIL THE INTERVIEW. HAND R SHOWCARD
X.
ALL MONTH LINES NEED TO HAVE AN ENTRY IN ONE OF THE LAST THREE COLUMNS.
E1a. Thinking of the past year, that would be from until now, what months did you
participate in a food program? Let’s start with . During this month were you participating in
SNAP/Food Stamps, FDPIR or neither? CONTINUE ASKING ABOUT EACH MONTH.
MONTH
YEAR
SNAP
FDPIR
NEITHER
2013
[Objective 3.2]
22
FDPIR Survey updated 9/10/11
E2
I see that you did not participate in either FDPIR or SNAP in ? Can you tell me why? THIS MAY INVOLVE CONSECTUTIVE OR NONCONSECUTIVE MONTHS. ASK ABOUT ALL MONTHS AND LIST UNTIL ALL
REASONS HAVE BEEN ACCOUNTED FOR.
(RECORD VERBATIM AND CODE)
SOURCE: Project-developed question and response set. [Objective 3.2]
E3.
Was not eligible (income
related reason)
Did not apply in time
Was receiving food
benefits through another
household
Had other sources of
food (personal,
community)
Did not live in the area
Other (SPECIFY): _____
I see that you changed from FDPIR to SNAP/Food Stamps in
. What was the reason/were the reasons for changing
from FDPIR to SNAP?
HAND RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD.
MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL
CHANGES HAVE BEEN ACCOUNTED FOR.
A. Because the size and income resources of my household
changed so I was now eligible for SNAP [change in eligibility]
B. Because I participate in the TANF program
C. Because I prefer having a greater variety of food choices or
options [greater food choices]
D. Because the food in the store/supermarket is better quality
than the USDA Foods [better food quality]
E. Because I have less time to prepare and cook food , don’t
know how to cook, don’t like to cook or don’t have the time to
cook, needed greater flexibility and can buy convenience and
prepared foods [greater convenience in food preparation]
F. Because I needed to buy specific foods for household
members (e.g., dietary restrictions) [changes in household
food/dietary needs]
G. In the summer I have more responsibility for feeding children
not in school.
H. Because I have greater privacy obtaining food using the EBT
card [personal preference; privacy]
I. Because I can use the EBT card at a convenience store or gas
station [greater convenience]
J. Because the store/market is closer to where I live than the
distribution site [better access, more convenient]
K. Because I was going away for a period of time and would be
able to use SNAP benefits anywhere [greater convenience]
L. Because I think I can get more food on SNAP benefits than
FDPIR
M. Because . . . [Respondent supplies reason] [Other]
SWITCH FDPIR to SNAP
A
B
C
D
E
F
G
H
I
J
K
L
M
[Objective 3.31]
23
FDPIR Survey updated 9/10/11
I see that you changed from SNAP/Food Stamps to FDPIR in
. What was the reason/were the reasons for
changing from SNAP to FDPIR?
HAND RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD.
MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL
CHANGES HAVE BEEN ACCOUNTED FOR.
A. Because it is easier to qualify for FDPIR [lower income threshold]
B. Because I receive a greater quantity of food through FDPIR
[increased food quantity]
C. Because the quality of the USDA Foods is better [better food
quality]
D. Because I wanted to stock up on canned and dried goods
[stocking up on food]
E. Because I don’t like the SNAP/food stamp certification process,
because I don’t like the way I am treated at the county office or
similar problem. [dissatisfaction with certification process]
F. Because the county office is too far way and difficult to get to
[inconvenient location]
G. Because the FDPIR pick-up/distribution site is closer than going to
the store/market [easier access]
H. Because I don’t know how to use/feel comfortable using an EBT
card [personal preference; discomfort with using EBT]
I. Because I feel that people in the store/market look down on me
when I use the EBT card [perception of stigma]
J. Because . . . [Respondent supplies reason] [Other]
E4
E5
SOURCE: Project-developed question and response set based on content
analysis of 2009 Urban Institute site visit reports, review of Usher et al 1990,
and comments during January 2012 USDA/FDPIR Tribal Consultations
[Objective 3.3]
You said that your household received SNAP/Food Stamps during the last
year. About how much was the amount received each month?
Has any member of the household ever been disqualified from participation
in the FDPIR program?
IF YES: Please explain:(RECORD VERBATIM)
SWITCH SNAP to FDPIR
A
B
C
D
E
F
G
H
I
J
$______ Monthly
Yes
No
Don’t Know
Refused
24
FDPIR Survey updated 9/10/11
Section F: Nutrition Education and Other Services
The next few questions ask about nutrition education and other health related services.
F1
FDPIR offers nutrition education information and activities on-line and
in person. Examples of these include distributing newsletters,
factsheets, recipes, providing nutrition counseling, or holding cooking
demonstrations and nutrition classes. Have you or anyone in your
household used or taken part in any of these activities in the past year?
F1a. IF NO: Was this because they were not offered, no one
was interested, considered to be not useful, no
computer/internet access, timing not good, location
inconvenient, no transportation or some other reason.
(RECORD VERBATIM AND CODE)
F1b. IF YES, HAND SHOWCARD TO R: I am going to read you a
list of items, please tell me if during the past year anyone in
your household picked up any of the educational offerings or
took part in any of the activities that included nutrition
education . . . (READ EACH CATEGORY AND CHECK () THE ‘YES’
CATEGORIES )
IF CHECKED: Approximately how often?
Newsletters ………………………………….
Factsheets ……………………………………
Recipes/Cookbooks ………………………
DVDs …………………………………………….
Calendars ………………………………………
How to budget ………………………………
How to grocery shop ……………………..
Cooking demonstrations ………………..
Baking demonstrations ………………….
Demonstrations on how to preserve
food ………………………………………………
Demonstrations on using traditional
foods …………………………………………….
Tastings during FDP pick-up …………..
Nutrition classes ……………………………
Nutrition counseling ……………………..
‘Pot luck’ or similar types of
gatherings …………………………………….
Kid nutrition …………………………………
Mothers’ Groups …………………………
Demonstrations on or participation
in gardening ………………………………….
Yes
No
Don’t Know
Refused
Not offered
Not interested
Not useful
No computer/ internet access
Timing not good
Location inconvenient
No transportation
Other (SPECIFY): ___________
_________________________
Don’t Know
Refused
FREQUENCY (PER YEAR)
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
____ Times
25
FDPIR Survey updated 9/10/11
Gardening education …………………….
Health/Nutrition fairs ……………………
Other (SPECIFY): ________________
Other (SPECIFY): ________________
____ Times
____ Times
____ Times
____ Times
____ Times
IF F1b RESPONSES ARE ALL NOT CHECKED SKIP TO F2.
IF ANY CHECKED IN F1b ASK F1c.
F1c. You indicated someone in the household read or
participated in the following FDPIR offerings . Have any changes been made to the
household cooking or eating practices as a result of these
programs, activities, or information?
F1d. IF YES: What changes have been made? RECORD
VERBATIM
___________________________________________________
___________________________________________________
F1e. IF NO: Why not? RECORD VERBATIM
___________________________________________________
__________________________________________________
F2
SOURCE: Project-developed question and response set, based on
content analysis of 2009 Urban Institute site visit reports.
[Objective 6.3]
Other program services offered by FDPIR alone or in coordination with
other programs are fitness and health classes, cooking classes, health
fairs and the like. Have you or anyone in your household taken part in
such activities?
F2a. IF YES to F2: Were there any changes in activity or health/fitness
because of these services/activities?
IF YES TO F2a1: What were the changes?
Yes (ASK F2a)
No (SKIP TO F3)
Don’t Know
Refused
Yes (ASK F2a1)
No (ASK F2a2)
Don’t Know
Refused
IF NO TO F2a2: Why not?
26
FDPIR Survey updated 9/10/11
F2b. IF YES to F2: Were there any changes in diet and health because
of these services/activities?
IF YES TO F2b1: What were the changes?
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
IF NO TO F2b2: Why not?
F2c. IF YES to F2: Were there any changes in food preparation because
of these services/activities?
IF YES TO F2c: What were the changes?
IF NO TO F2c: Why not?
SOURCE: Project-developed question and response set. [Objective 6.2]
F3
Has FDPIR staff ever referred your household to other assistance
services or programs like cash assistance or child support for example?
F3a. If YES, which one(s)? CHECK ALL THAT APPLY. PROVIDE
A CARD WITH THE LIST
Head Start
Tribal TANF
Emergency Assistance
General Assistance
Elder Care
Subsidized Housing
Child Support
Indian Child Welfare
Vocational Education
Vocational Rehabilitation
Health & Wellness
Mental Health
Domestic Violence
Substance Abuse
Other (SPECIFY):
____________
27
FDPIR Survey updated 9/10/11
F3b. Are any of these programs or services provided in the
same location as FDPIR?
If YES, which one(s)?
CHECK ALL THAT APPLY
SOURCE: Project-developed question and response set.
[Objective 5.5]
Yes
No
Don’t Know
Refused
Head Start
Tribal TANF
Emergency Assistance
General Assistance
Elder Care
Subsidized Housing
Child Support
Indian Child Welfare
Vocational Education
Vocational Rehabilitation
Health & Wellness
Mental Health
Domestic Violence
Substance Abuse
Other (SPECIFY):
____________
28
FDPIR Survey updated 9/10/11
Section G: Satisfaction with FDPIR
We are now going to talk about your satisfaction with FDPIR.
G1
HAND RESPONDENT SHOWCARD X
What was your household’s most important reason for seeking food
assistance? (RECORD VERBATIM AND CODE ANSWER)
a.
b.
c.
d.
e.
SOURCE: Project-developed question and response set.
f.
g.
h.
G2
HAND RESPONDENT SHOWCARD X
What was your household’s most important reason for enrolling in FDPIR?
(RECORD VERBATIM AND CODE ANSWER)
a.
b.
c.
d.
Loss of job
Loss of other source of
income
Household became
eligible for FDPIR
FDPIR was more
convenient than other
programs
FDPIR changed its
delivery options and it
became easier for our
household
Loss of other benefits
Established own
household
Other (SPECIFY)
Household became
eligible for FDPIR
FDPIR was more
convenient than other
programs
FDPIR changed its
delivery options and it
became easier for our
household
Other (SPECIFY)
SOURCE: Project-developed question and response set.
G3
FDPIR offers a variety of foods including vegetables, dry beans, juice, fruits,
meats, ready to eat cereals, and miscellaneous items such as dry egg mix,
cheese, crackers, noodles, peanut butter, milk and pasta to name a few.
G3a. In terms of variety how satisfied are you? Very satisfied,
somewhat satisfied, neither satisfied or dissatisfied, somewhat
dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3b. In terms of freshness how satisfied are you? Very satisfied,
somewhat satisfied, or not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
29
FDPIR Survey updated 9/10/11
Very dissatisfied
G3c. In terms of quality how satisfied are you? Very satisfied,
somewhat satisfied, neither satisfied or dissatisfied, somewhat
dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3d. In terms of nutritional value how satisfied are you? Very
satisfied, somewhat satisfied, neither satisfied or dissatisfied,
somewhat dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3e. In terms of taste appeal (PROBE: salty, sweet, sour, old, stale,
greasy) how satisfied are you? Very satisfied, somewhat satisfied,
neither satisfied or dissatisfied, somewhat dissatisfied or very
dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3f. In terms of visual appeal of packaging and food how satisfied
are you? Very satisfied, somewhat satisfied, neither satisfied or
dissatisfied, somewhat dissatisfied or very dissatisfied?
IF NOT SATISFIED: Why are you not satisfied?
G3g. What is your overall satisfaction with the FDPIR food package?
What do you like most? What do you like least? What foods would
you like to see added? Are any of these food considered
cultural/traditional foods?
IF NOT SATISFIED: Why are you not satisfied?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
SOURCE: Project-developed question and response set. [Objective 9.1]
30
FDPIR Survey updated 9/10/11
G4
Generally, do you, and members of your household, feel that the FDPIR
programs meets your food and nutrition needs?
G4a IF YES: Could you tell me more about how it has met your food
and nutrition needs? (RECORD VERBATIM)
Yes (SKIP TO G4a)
No (SKIP TO G4b)
Don’t Know
Refused
G4b IF NO: Could you tell me more how the program has not met
your food and nutrition needs? (RECORD VERBATIM)
SOURCE: Project-developed question and response set. [Objective 9.1]
G5
Please tell me your overall satisfaction about the following aspects of your
experiences with FDPIR. Are you very satisfied, somewhat satisfied or not
satisfied with the following aspects of FDPIR:
IF NOT SATISIFIED ASK: What is the reason you are/were not satisfied?
G5a. Application process
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5b. Recertification process
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5c. Location of distribution site
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G5d. Attractiveness/atmosphere of distribution site
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
31
FDPIR Survey updated 9/10/11
Very dissatisfied
G5e. Features of the distribution facility
[PROBES: Sufficient parking, children’s play area, help carrying FDPIR
food package items to the car]
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4f. Frequency of distribution
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4g. Interaction with program staff
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4h. Nutrition Education offerings
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
G4i. Other program factors (SPECIFY) :_________________________
SOURCE: Project-developed question and response set. [Objective 9.1]
G6
Have there been any changes in FDPIR in the past three years that have
influenced your participation in the program?
Very satisfied
Somewhat satisfied
Neither satisfied or
dissatisfied
Somewhat dissatisfied
Very dissatisfied
Yes (SKIP TO G5A)
No
Don’t Know
Refused
G5a. IF YES: What changes? (RECORD VERBATIM)
32
FDPIR Survey updated 9/10/11
G5b. How did the changes influence your participation? (RECORD
VERBATIM.)
SOURCE: Project-developed question and response set.
G7
If you had the opportunity what would you tell the Federal Government about
the FDPIR program? (RECORD VERBATIM – PROBE FOR COMPLETENESS)
Nothing/No
comment
Refused
SOURCE: Project-developed question and response set, based on Bell-Sheeter,
2004.
G8
G9
If you had the opportunity what would you tell your tribal leaders about the
FDPIR program? (RECORD VERBATIM – PROBE FOR COMPLETENESS)
SOURCE: Project-developed question and response set, based on Bell-Sheeter,
2004.
Would you recommend the FDPIR program to other family and friends?
G8a. IF NO: Why not? (RECORD VERBATIM)
Nothing/No
comment
Refused
Yes
No
Don’t Know
Refused
SOURCE: Project-developed question and response set.
33
FDPIR Survey updated 9/10/11
Section H: Ending the Interview
Those are all of the survey questions I have. Thank you so much for taking the time to speak with me.
Do you have any questions about the survey or the experience?
H1
In appreciation for the time spent with me the project would like to give you
$25.00/gift card. HAVE RESPONDENT SIGN THE RECEIPT.
H2
The office may want to call you to verify that the interview was conducted.
What is the best phone number to reach you?
H2a. What is the best time of day to reach you? Morning, afternoon
or evening?
$25.00
Gift Card
___ - ___ - ____
1.
2.
3.
AM
PM
Evening
H3
DATE OF INTERVIEW: _____/_____/_____
INTERVIEWER NAME: ______________________________________
ID NUMBER: _________________________
IS THERE ANYTHING YOU WOULD LIKE TO SAY ABOUT THIS INTERVIEW?
Time Ended: __:____
34
| File Type | application/pdf |
| Author | Pindus, Nancy |
| File Modified | 2013-02-25 |
| File Created | 2013-02-25 |