FDPIR Survey updated 2/25/13
OMB NUMBER: 0584-XXXX
EXPIRATION DATE: XX-XX-20XX
ATTACHMENT B2a: HOUSEHOLD SURVEY
BURDEN DISCLOSURE STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
INTERVIEWER: BEFORE STARTING INTERVIEW PLEASE ENTER AVAILABLE AIS DATA IN QUESTION E1.
FDPIR Household 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.
PARTICIPANT 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. You will receive the gift card even if you decide to end the survey early. The interview will take about 30 minutes.
The information you provide will be kept private, 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 that summarizes the survey findings will be shared with the tribe/native village at a later date, but it will not include names of individuals or tribes/native villages.”
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.
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:
Note: 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.
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 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 kept private, 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 that summarizes the findings will be shared with the tribe/native village at a later date. Names of individuals or tribes/native villages will not be used in the report. All information is aggregated at the national level. A report that summarizes the survey findings will be shared with the tribe/native village at a later date, but it will not include names of individuals or tribes/native villages.
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.
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)
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 Translator: _____________________________________________________________
Signature of Translator __________________________________________________________
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)
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?
IF RESPONDENT SAYS ‘YES’ TO ANY OF THE CATEGORIES ADD THAT PERSON(S) TO THE LIST ON THE GRID. |
2 |
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? |
3 |
ASK OR VERIFY GENDER OF EACH PERSON LISTED. |
4 |
How old were (you/person) on your/his/her last birthday? |
5 |
FOR EACH PERSON 16 YEARS AND OLDER ASK: What is (your/person’s) current marital status. Is he/she married, never married, separated, widowed or divorced? |
6 |
FOR EACH PERSON ASK: What is the highest year of education (you/person) has completed? |
7 |
FOR EACH PERSON ASK: Are you/person currently a student? |
8 |
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? |
9 |
Does anyone in the household receive Social Security, SSI, LIHEAP, TANF or unemployment benefits? IF YES: Who and what do they receive? |
10 |
Does anyone in the household have access to the internet? IF YES: Who? |
11 |
Does anyone in the household own or lease a vehicle? IF YES: Who |
HOUSEHOLD ENUMERATION
Person # |
1. NAMES OF HOUSEHOLD MEMBERS |
2. REL TO APPLICANT |
3. GENDER |
4. AGE
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5. CURRENT MARITAL STATUS |
6. EDUCATION |
7. STUDENT Enter Yes/√ |
8. EMPLOYMENT STATUS |
8a. HOURS PER WEEK |
9. OTHER BENEFITS
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10. INTERNET ACCESS Enter Yes/√ |
11. OWN/ LEASE VEHICLE Enter Yes/√ |
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Relationship to Applicant |
Current Marital Status |
Education |
Employment Status |
Other Benefits |
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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
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l. Brother/sister m. Grandparent n. Uncle o. Aunt p. Cousin q. Nephew/niece r. Father-in-law s. Mother-in-law t. Bro/sis-in-law u. Other-in-law v. Other non-relative
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Married (M) Never married (NM) Separated (S) Divorced (D) Widowed (W) |
Refused |
(SPECIFY) |
a. SS b. LIHEAP c. TANF d. Unemployment Insurance. e. SSI |
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Section A: Participant and Household Characteristics |
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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. |
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A1 |
First, do you live within or off the reservation/ pueblo/ Rancheria/ Alaska native village/ tribal service area?
SOURCE: Household Survey, Assessment of Native American, Alaska Native, and Native Hawaiian Housing Needs (NAHSG) (HUD/PD&R) [Objective 1.9] |
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A2 |
Which of the following equipment or methods of food storage and preparations do you use in your home? [Check all that apply]
SOURCE: Bell-Sheeter 2004, Food Sovereignty Assessment Tool [Objective 1.10] |
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A3 |
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.
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Person # ___ Other (Specify)
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A4 |
What is your main source of water for preparing meals? Is it… Public or private water system
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Other (SPECIFY): ________________________ |
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. I am going to show you/read a list to you with the responses or you can add your own. Do you or your family receive any medical services on the reservation/pueblo/Rancheria/Alaska native village/tribal service area?
IF YES: What are the sources of these services? (HAND/READ SHOWCARD X TO RESPONDENT) MARK ALL THAT APPLY
SOURCE: Project-developed question. Response categories based on content analysis of Indian Health Service regions and tribally-managed health services. [Objective 1.4]
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A6 |
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:
SOURCE: NHANES HEALTH INSURANCE QUESTIONNAIRE (HIQ) [Objective 1.4] |
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
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A7 |
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 …………………………………………………………
A7e. Cancer ……………………………………………………………………
A7f. Underweight …………………………………………………………….
A7g. Liver disease …………………………………………………………..
A7h. Gastro-intestinal problems (e.g., Irritable Bowel Syndrome, ulcers, lactose intolerance, diarrhea) ………………………………………………………………………..
A7i. Vitamin or mineral deficiencies or anemia ……………….
A7j. Other (SPECIFY)_______________..............................
SOURCE: Based on Usher et al, 1990. [Objective 1.11] |
Refused
Refused |
A8 |
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]
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#: ___ |
A9 |
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] |
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A10 |
HAND/READ SHOWCARD X TO RESPONDENT
Now I would like to ask about your rent or mortgage payments. Do not include utilities.
In-person: 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.
Telephone: Please listen to the options and tell me the letter that corresponds to the amount you pay for your rent or mortgage.
SOURCE: Project-developed question and response set. [Objective 1.9] |
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A11 |
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. HAND/READ SHOWCARD X TO RESPONDENT
In-person: Please look at this card and tell me the amount you pay each month.
Telephone: Please listen to the options and tell me the amount you pay each month.
What utilities/services are included in that amount? |
Gas Electricity Water Trash collection Telephone Other (SPECIFY) __________ |
Section B: FDPIR Contribution to Food Supply |
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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. |
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B1
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I am going to read you three 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?
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?
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?
B1d. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?
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?
SOURCE (B1a-e): US Household Food Security Survey Module: Six-Item Short Form[HH3, HH4, AD1, AD1a, AD2, AD3]
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B2 |
How did you learn about FDPIR? (RECORD VERBATIM and CODE ANSWER)
SOURCE: Project-developed question and response set. [Objective 5.1] |
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B3 |
Is FDPIR the only or primary source of food for this household?
I will show you a list/read you a list with some responses to choose from or you can add your own.
B3a. Thinking of the other sources of food for this household, what percentage comes from:
(READ CATEGORIES BELOW AND HAND/READ RESPONDENT SHOWCARD X).
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]
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____% 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): __________
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B4 |
Is anyone in your household receiving benefits from or participating in food programs other than FDPIR? I will show you a list/read you a list with some responses to choose from or you can add your own. Examples would include (READ CATEGORIES BELOW AND HAND/READ RESPONDENT SHOWCARD X).
• Head Start (CACFP)
B4a. IF YES: Which ones?
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]
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□ Head Start (CACFP)
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B5 |
Has anyone in your household been referred to other food programs by the FDPIR staff? I will show you a list/read you a list with some responses to choose from or you can add your own. Examples would include (READ CATEGORIES BELOW AND HAND/READ RESPONDENT SHOWCARD X).
B5a. IF YES: Which programs?
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□ Head Start (CACFP) □ School Breakfast Program
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B6 |
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]
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B7 |
During the past month did you or anyone in your household get any meals that were prepared outside your home by extended family or prepared by a community group?
B7A. IF YES: How often did the household eat meals prepared outside your home by extended family or prepared by a community group? Would you say none, some, about half or most meals?
SOURCE: Project-developed question and response set. [Objective 2.1] |
Yes □ No □ Don’t Know □ Refused
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Section C: Access to FDPIR - Distribution and Delivery |
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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. |
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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?
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?
SOURCE: Project-developed question and response set. [Objective 1.7] |
___ Miles
___ HRS ___ MINS
1. Own car or truck 2. Someone else drove SPECIFY: 3. Walked 4. Public transportation 5. Taxi 6. Some other way SPECIFY: ________________
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C2 |
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] |
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C3 |
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)
SOURCE: Project-developed question and response set. [Objective 9.1]
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_______________________
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C4 |
Thinking about picking up your food packages, approximately how many miles do you have to travel to pick up the food packages?
C4a. About how long does it usually take to get there?
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?
SOURCE: Project-developed question and response set. [Objective 1.7] |
___ Miles
___ HRS ___ MINS
1. Own car or truck 2. Someone else drove SPECIFY: ________________ 3. Walked 4. Public transportation 5. Taxi 6. Some other way SPECIFY: ________________
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C5 |
Do you have an authorized representative pick up your food packages?
C5a. IF YES: Approximately how many miles does the representative travel to pick up the food packages?
C5b. About how long does it usually take your representative to get there?
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]
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___ Miles
___ HRS ___ MINS
1. Own car or truck 2. Someone else drove SPECIFY: ________________ 3. Walked 4. Public transportation 5. Taxi 6. Some other way SPECIFY:________________
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C6 |
Does traveling to the FDPIR site present any challenges or problems for you? [Objective 4.4]
C6a. IF YES, please describe why this is challenging (SPECIFY).
C6b. Is home delivery an option that is offered by the FDPIR program?
SOURCE: Project-developed question and response set. [Objective 1.7]
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Section D: Food Access and Cost – Non-subsidized Sources |
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We are also interested in finding out how easy or hard it is to obtain food in your area and about food costs. |
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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 ……………………………………
D1b. Nearest grocery store………………………………………………………………………………
D1c. Nearest convenience store……………………………………………………………………….
D1c. Nearest farmers market………………………………………………………………………………
D1d. Nearest warehouse/ department/large, big-box store that sells groceries (such as Walmart, Target, Costco, Sam’s Club)) ……………………
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____Miles ___ Hrs/Mins
____Miles ___ Hrs/Mins
____Miles ___ Hrs/Mins
____Miles ___ Hrs/Mins
____Miles ___ Hrs/Mins
____Miles ___ Hrs/Mins
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D2 |
Thinking about the past year, that would be from about <MONTH/YEAR>, 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.
D2a. IF YES: What are these changes? (RECORD VERBATIM)
SOURCE: Project-developed question and response set. |
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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? D3c. Why is that? RECORD VERBATIM:
___________________________________________________________
D3d. Are there seasons when you household spends considerable more on food expenses? (IF NO, SKIP TO SECTION E)
D3e. Which seasons?
D3f. Why is that? RECORD VERBATIM
SOURCE: Project-developed question and response set.
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$_____
SEASON: ___________ SEASON: ____________
SEASON: ___________ SEASON: ____________
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Section E: Participation in FDPIR and SNAP/Food Stamps |
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The next few questions will be about whether your household has also participated in SNAP/Food Stamp program as well as FDPIR, if you have ever switched between the two programs, and your reasons for doing so. |
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E2 |
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/READ RESPONDENT 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 <MONTH/YEAR>until now, what months did you participate in a food program? Let’s start with <MONTH/YEAR>. During this month were you participating in SNAP/Food Stamps, FDPIR or neither? CONTINUE ASKING ABOUT EACH MONTH.
[Objective 3.2]
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E3 |
I see that you did not participate in either FDPIR or SNAP in <MONTHS, YEARS>? Can you tell me why? THIS MAY INVOLVE CONSECTUTIVE OR NON-CONSECUTIVE 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] |
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E4. |
I see that you changed from FDPIR to SNAP/Food Stamps in <MONTHS/YEARS>. I will show you a list/read you a list with some responses to choose from or you can add your own. What was the reason/were the reasons for changing from FDPIR to SNAP? HAND/READ RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD. MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL CHANGES HAVE BEEN ACCOUNTED FOR.
[Objective 3.31] |
SWITCH FDPIR to SNAP
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I see that you changed from SNAP/Food Stamps to FDPIR in <MONTHS/YEARS>. I will show you a list/read you a list with some responses to choose from or you can add your own. What was the reason/were the reasons for changing from SNAP to FDPIR?
HAND/READ RESPONDENT SHOWCARD X AND READ THE STATEMENTS ALOUD. MARK ALL THAT APPLY. CONTINUE GOING THROUGH THE LIST UNTIL ALL CHANGES HAVE BEEN ACCOUNTED FOR.
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] |
SWITCH SNAP to FDPIR
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E5 |
You said that your household received SNAP/Food Stamps during the last year. About how much was the amount received each month?
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$______ Monthly
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E6 |
Has any member of the household ever been disqualified from participation in the FDPIR program?
IF YES: Please explain:(RECORD VERBATIM)
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Section F: Nutrition Education and Other Services |
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The next few questions ask about nutrition education and other health related services. |
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F1
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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 /READ SHOWCARD TO RESPONDENT: 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 F1b RESPONSES ARE NO SKIP TO F1e.
IF YES IN F1b ASK F1c.
F1c. You indicated someone in the household read or participated in the following FDPIR offerings <MENTION ALL CHECKED FROM >. 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
_____________________________________________________________________________________________________
SOURCE: Project-developed question and response set, based on content analysis of 2009 Urban Institute site visit reports. [Objective 6.3] |
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YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO
YES NO
YES NO YES NO YES NO YES NO
YES NO YES NO YES NO YES NO
YES NO YES NO YES NO YES NO
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F2 |
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 F2a: What were the changes?
IF NO TO F2a: Why not?
F2b. IF YES to F2: Were there any changes in diet and health because of these services/activities?
IF YES TO F2b: What were the changes?
IF NO TO F2b: 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]
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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
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]
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Section G: Satisfaction with FDPIR |
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We are now going to talk about your satisfaction with FDPIR. |
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G1 |
HAND/READ RESPONDENT SHOWCARD X What was your household’s most important reason for seeking food assistance through FDPIR? (RECORD VERBATIM AND CODE ANSWER) I will show you a list/read you a list with some responses to choose from or you can add your own.
SOURCE: Project-developed question and response set.
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G2 |
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.
G2a. 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?
IF NOT SATISFIED: Why are you not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
IF NOT SATISFIED: Why are you not satisfied?
SOURCE: Project-developed question and response set. [Objective 9.1]
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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
Very satisfied Somewhat satisfied Neither satisfied or dissatisfied Somewhat dissatisfied Very dissatisfied
Very satisfied Somewhat satisfied Neither satisfied or dissatisfied Somewhat dissatisfied Very dissatisfied
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G3 |
Generally, do you, and members of your household, feel that the FDPIR programs meets your food and nutrition needs?
G3a IF YES: Could you tell me more about how it has met your food and nutrition needs? (RECORD VERBATIM)
G3b 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]
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G4 |
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?
G4a. Application process
G4b. Recertification process
G4c. Location of distribution site
G4d. Attractiveness/atmosphere of distribution site
G4e. Features of the distribution facility [PROBES: Sufficient parking, children’s play area, help carrying FDPIR food package items to the car]
G4f. Frequency of distribution
G4g. Interaction with program staff
G4h. Nutrition Education offerings
G4i. Other program factors (SPECIFY) :_________________________
SOURCE: Project-developed question and response set. [Objective 9.1]
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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
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
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G5 |
Have there been any changes in FDPIR in the past three years that have influenced your participation in the program?
G5a. IF YES: What changes? (RECORD VERBATIM)
G5b. How did the changes influence your participation? (RECORD VERBATIM.)
SOURCE: Project-developed question and response set.
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G6 |
If you had the opportunity, what would you tell the Federal Government about the FDPIR program? (RECORD VERBATIM – PROBE FOR COMPLETENESS)
SOURCE: Project-developed question and response set, based on Bell-Sheeter, 2004.
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G7 |
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. |
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G8 |
Would you recommend the FDPIR program to other family and friends?
G8a. IF NO: Why not? (RECORD VERBATIM)
SOURCE: Project-developed question and response set. |
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Section H: Ending the Interview |
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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? |
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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 (in-person interview).
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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?
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___ - ___ - ____
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H3 |
DATE OF INTERVIEW: _____/_____/_____
INTERVIEWER NAME: ______________________________________
ID NUMBER: _________________________
IS THERE ANYTHING YOU WOULD LIKE TO SAY ABOUT THIS INTERVIEW?
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Time Ended: __:____
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |