Individual/Households

APPENDIX D1 - Client Survey

OMB No.: 0584-XXXX

Expiration Date: XX/XX/XXXX

Assessment of the Contributions of an Interview to Supplemental Nutrition Assistance Program Eligibility and Benefit Determinations

May 2012

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0584-XXXX. Public reporting burden for this collection of information is estimated to be 10 minutes per response including the time for participating in the interviews and providing the extant data collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA, 22302, ATTN: Rosemarie Downer.

INTRODUCTION

May I speak with [fill SAMPLE MEMBER NAME]. My name is [fill INTERVIEWER’S NAME] from Mathematica Policy Research. I am conducting a study about <INSERT STATE PROGRAM NAME, if not SNAP> for the U.S. Department of Agriculture. The USDA recently sent you a letter asking you to spend 5 minutes sharing your experiences. We will mail you a $10 gift card after you complete this survey to thank you. Incentives for participating in this survey will not count against your income eligibility for SNAP benefits.

The purpose of this study is to find out about your experiences with [STATE]’s Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program) with SNAP application process. Your participation will help to improve the SNAP application process. Information about your experiences can help policymakers improve the program. You will be asked to share your experiences with different stages of the SNAP application process. This research has been approved by our Institutional Review Board, Public/Private Ventures.

The benefit of participating in this survey is that it will help to improve the SNAP application process. Information about your experiences can help policymakers improve the program. Participation in this study is voluntary. Deciding to participate or not to participate will not affect any benefits you are receiving now or in the future. By participating in this survey, you are giving us consent to use the information collected today in the reporting of the results of this study. All individual information is private and will not be used in any way that could identify you. The only minimal risk which could arise from participating is a breach of privacy. Responses will only be reported in larger groups.

Do you agree to participate in the survey?

CODE ONE ONLY

YES [SIGN & DATE ORAL CONSENT] 1

NOT A GOOD TIME, SCHEDULE CALLBACK 2

HUNG UP DURING INTRODUCTION 3

DOES NOT SPEAK ENGLISH 4

WRONG NUMBER 5

REFUSED r

Before we begin, do you have any questions?

ORAL CONSENT

NOTE TO INTERVIEWER: IF RESPONDENT AGREES TO PARTICIPATE, PLEASE SIGN YOUR NAME AND RECORD THE DATE AND TIME PARTICIPANT GAVE ORAL CONSENT:

Interviewers Name:

Date of oral consent:

Time of oral consent:

Please answer these questions thinking only about your recent experiences [applying for/renewing] your [INSERT STATE PROGRAM NAME] benefits in the last few months. Do not answer about any prior experiences with the [INSERT STATE PROGRAM NAME].

A1. Did you complete your [INSERT STATE PROGRAM NAME] application by computer or on paper?

IF COMPUTER: Was the computer at the [INSERT PROGRAM NAME] office or somewhere else?

IF PAPER: Did you submit the application in person or by mail or fax?

CODE ONE ONLY

ELECTRONICALLY USING A COMPUTER at snap office 1

ELECTRONICALLY USING A COMPUTER not at snap office 2

IN PERSON USING PAPER APPLICATION 3

BY MAIL or fax USING PAPER APPLICATION 4

SOME OTHER WAY (SPECIFY) 99

__________________________________________

DON’T KNOW d

REFUSED r

A2. After you submitted your application, did you have an interview with a caseworker to review your application or to provide more information?

CODE ONE ONLY

yes 1

NO 0 GO TO A4

DON’T KNOW d GO TO A4

REFUSED r GO TO A4

A3. How did this interview take place?

CODE ONE ONLY

IN PERSON 1

BY TELEPHONE 2

SOME OTHER WAY (SPECIFY) 99

___________________________________________

DON’T KNOW d

REFUSED r

RESPONDENTS IN COMPARISON SITES GO TO B1

[IF SAMPLE=COMPARISON, GO TO B1]

ASK A4 IF RESPONDENT WAS FROM A NO INTERVIEW SITE AND HAD NO INTERVIEW. IF NOT, GO TO A6.

[ASK A4 IF SAMPLE=NO INTERVIEW AND A2=2,d or r; IF NOT, GO TO A6]

A4. Did you receive any information letting you know about how to request a telephone or in-person interview, if you desired one?

CODE ONE ONLY

YES 1

NO 0

DON’T KNOW d

REFUSED r

A5. Were you contacted directly at any time for any missing or incomplete information on your application?

CODE ONE ONLY

YES 1

NO 0

DON’T KNOW d

REFUSED r

GO TO B3

A6. Did you choose to have an interview or were you contacted directly for more information on your application?

CODE ONE ONLY

chose interview 1

CONTACTED DIRECTLY 2 GO TO B1

DON’T KNOW d GO TO B1

REFUSED r GO TO B1

A7. Why did you choose to have the interview?

CODE ALL THAT APPLY

WANTED TO SPEAK TO A PERSON 1

FOUND INSTRUCTIONS CONFUSING 2

BEST CHANCE TO BE APPROVED 3

OTHER (SPECIFY) 99

___________________________________________

DON’T KNOW d

REFUSED r

ASK B1 IF APPLICANT HAD INTERVIEW, OTHERWISE GO TO B3

[ASK B1 IF A2=1 AND A6<>2; IF NOT GO TO B3]

B1. Did you have any difficulties scheduling your interview?

CODE ONE ONLY

YES 1

NO 0 GO TO B3

DON’T KNOW d GO TO B3

REFUSED r GO TO B3

B2. What were the difficulties?

CODE ALL THAT APPLY

NO CONVENIENT TIMES 1

HARD TO REACH SOMEBODY 2

DIDN’T UNDERSTAND PROCESS 3

LOCATION DIFFICULT TO GET TO 4

OTHER (SPECIFY) 99

___________________________________________

DON’T KNOW d

REFUSED r

B3. During the application process, did you have difficulty providing information needed about your family and your financial situation (i.e. income, savings, employment)?

CODE ONE ONLY

YES 1

NO 0 GO TO C1

DON’T KNOW d GO TO C1

REFUSED r GO TO C1

B4. What were the difficulties?

CODE ALL THAT APPLY

LOCATING DOCUMENTS 1

DEADLINE TOO SHORT 2

INSTRUCTIONS WERE CONFUSING 3

DIDN’T UNDERSTAND PROCESS 4

OTHER (SPECIFY) 99

___________________________________________

NO 0

DON’T KNOW d

REFUSED r

C1. Did you seek any help in completing the application process?

PROBE: (IF NECESSARY: Such as help with understanding or translating the instructions, filling out the application, or getting transportation to the SNAP office.)

CODE ONE ONLY

YES 1

NO 0 GO TO D1

DON’T KNOW d GO TO D1

REFUSED r GO TO D1

C2. Where did you seek help from?

CODE ALL THAT APPLY

SNAP OFFICE STAFF 1

ORGANIZATION IN THE COMMUNITY (e.g., BENEFITS DATA TRUST, LIBRARY, SENIOR CENTER, OUTREACH WORKER OR LEGAL AID REPRESENTATIVE) 2

RELATIVE, FRIEND, OR NEIGHBOR 3

CLERGY 4

WEBSITES/INTERNET 5

OTHER (SPECIFY) 99

__________________________________________

DON’T KNOW d

REFUSED r

C3. Did this help make the application process easier?

CODE ONE ONLY

YES 1

NO 0

DON’T KNOW d

REFUSED r

ASK C4 IF MULTIPLE RESPONSES TO C2

C4. Which type of help was most useful?

PROBE: [READ ALL RESPONSES FROM C2]

PROGRAMMER: LIST ONLY RESPONSES SELECTED IN C2

CODE ONE ONLY

SNAP OFFICE STAFF 1

ORGANIZATION IN THE COMMUNITY (e.g., BENEFITS DATA TRUST, LIBRARY, SENIOR CENTER, OUTREACH WORKER OR LEGAL AID REPRESENTATIVE) 2

RELATIVE, FRIEND, OR NEIGHBOR 3

CLERGY 4

WEBSITES/INTERNET 5

OTHER (SPECIFY) 99

___________________________________________

DON’T KNOW d

REFUSED r

D1. Please think about the following statement:

I felt [INSERT STATE PROGRAM NAME] staff were available to help me if I needed it.

Do you agree or disagree?

Strongly [agree/disagree] or somewhat [agree/disagree]?

CODE ONE ONLY

STRONGLY AGREE 1

SOMEWHAT AGREE 2

STRONGLY DISAGREE 3

SOMEWHAT DISAGREE 4

DON’T KNOW d

REFUSED r

D2. Next:

From the beginning, it was very clear how to use my [INSERT STATE PROGRAM NAME] benefit.

Do you agree or disagree?

Strongly [agree/disagree] or somewhat [agree/disagree]?

CODE ONE ONLY

STRONGLY AGREE 1

SOMEWHAT AGREE 2

STRONGLY DISAGREE 3

SOMEWHAT DISAGREE 4

DON’T KNOW d

REFUSED r

D3. Next:

I will know what to do if I need to renew my [INSERT STATE PROGRAM NAME] benefit.

Do you agree or disagree?

Strongly [agree/disagree] or somewhat [agree/disagree]?

CODE ONE ONLY

STRONGLY AGREE 1

SOMEWHAT AGREE 2

STRONGLY DISAGREE 3

SOMEWHAT DISAGREE 4

DON’T KNOW d

REFUSED r

D4. Overall, how satisfied were you with the [INSERT STATE PROGRAM NAME] application process? Were you satisfied or dissatisfied?

Strongly [satisfied/dissatisfied] or somewhat [satisfied/dissatisfied]?

CODE ONE ONLY

STRONGLY SATISFIED 1

SOMEWHAT SATISFIED 2

STRONGLY DISSATISFIED 3

SOMEWHAT DISSATISFIED 4

DON’T KNOW d

REFUSED r

D5. Were you satisfied or dissatisfied with the information you received about the [INSERT STATE PROGRAM NAME] program?

Strongly [satisfied/dissatisfied] or somewhat [satisfied/dissatisfied]?

CODE ONE ONLY

STRONGLY SATISFIED 1

SOMEWHAT SATISFIED 2

STRONGLY DISSATISFIED 3

SOMEWHAT DISSATISFIED 4

DON’T KNOW d

REFUSED r

D6. Was information about any other assistance programs shared with you during your [INSERT STATE PROGRAM NAME] application process?

CODE ONE ONLY

YES 1

NO 0 GO TO END

DON’T KNOW d GO TO END

REFUSED r GO TO END

D7. Was this information about…

CODE ALL THAT APPLY

TANF or other cash assistance programs, 1

Medical benefits (i.e. Medicaid, CHIP), 2

Child care, 3

WIC or other food assistance programs, or 4

Other programs in your community? (SPECIFY) 99

______________________________________________

DON’T KNOW d

REFUSED r

Those are all our questions. Thank you for participating in this survey. Do you have any questions?

Please tell me the name and address to send the gift card to.

Name:

Address:

For your records, along with the gift card, we will mail you a copy of the terms you agreed to at the beginning of survey about privacy and how the information will be used. This is also known as your consent to participate in this survey.

If you have any questions about the study please contact Eric Zeidman at (609) 936-2784.

If you have any questions about your rights as a research participant, please contact Melissia Billarrial at 1-800-755-4788, x4482.