SNMCS Individuals

N5. PARENT INTERVIEW (IN-PERSON OR TELEPHONE INTERVIEW)

This page has been left blank for double-sided copying.

OMB Clearance Number: 0584-XXX

Expiration Date: XX/XX/XXXX

ID#: | | | | | | | | |

SFA:

City and State:

PARENT INTERVIEW

Questionnaire

July 10, 2013

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 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

CHILD’S NAME:

SCHOOL ID:

CHILD ID #: | | | | | | | | |

GRADE:

CHILD’S GENDER:

MALE 1

FEMALE 2

RESPONDENT’S GENDER:

MALE 1

FEMALE 2

TYPE OF CHILD:

CHILD 1

YOUTH 2

LOCATION:

SCHOOL 1

HOME 2

PHONE 3

LANGUAGE:

ENGLISH 1

SPANISH 2

OTHER (SPECIFY) 99

(STRING (NUM))

INTRODUCTION FOR PARENT OF CHILDREN:

Okay, now that we completed the dietary recall I’d like to ask you some questions about your household and the meals provided by your child’s school.

INTERVIEWER: IF PARENT MENTIONED DURING DIETARY RECALL THAT CHILD HAD SCHOOL BREAKFAST, CODE “1” IN QUESTION 1 WITHOUT ASKING.

INTRODUCTION FOR PARENT OF YOUTHS:

Hello, my name is ______________ and I’m part of the study team that interviewed your child (yesterday/DAY) at school about the school meal programs. I’m calling now to see if we can do the parent interview. As you may recall from the letter and consent form sent home earlier, this study is being conducted by the U.S. Department of Agriculture to better understand how children and parents feel about the meals provided by schools, why they choose to participate or not participate in school meals, and how these decisions are related to children’s overall diets. The interview will take about 20 minutes, and your cooperation is completely voluntary. All answers you give will be kept private and no individual results will be presented. As a thank you for your time, we will be sending you $15.

INTERVIEWER: AFTER DETERMINING IF THE PARENT OR ADULT WHO KNOWS THE MOST ABOUT WHAT THE CHILD/YOUTH EATS IS ON THE PHONE, CONTINUE.

ASK ALL

First, I am going to ask you about (CHILD)’s eating habits and the food served at (his/her) school.

1. Some schools offer meals each day to children for free or at a set, fixed price. Does (CHILD)’s school have a school breakfast program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

2. Do you agree or disagree with the following statement: “School breakfasts should be available for all school children.” Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with that statement?

STRONGLY AGREE 1

SOMEWHAT AGREE 2

SOMEWHAT DISAGREE 3

STRONGLY DISAGREE 4

DON’T KNOW d

REFUSED r

3. Thinking back to the last full week of school, how often did (CHILD) eat breakfast? That is breakfast anywhere, at home or at school or somewhere else. Would you say (CHILD) ate breakfast every school day, ate breakfast on 3 or 4 school days, ate breakfast on 1 or 2 school days, or did not eat breakfast on any school days?

EVERY SCHOOL DAY 3

3 TO 4 SCHOOL DAYS 2

1 TO 2 SCHOOL DAYS 1

NO SCHOOL DAYS 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

IF NO SCHOOL BREAKFAST (Q.1=0), GO TO Q.10

4. Does (CHILD) ever eat a school breakfast, that is a complete breakfast provided by the school?

YES 1

NO 0 GO TO Q.6

DON’T KNOW d GO TO Q.6

REFUSED r GO TO Q.6

5. How many days a week does (CHILD) usually eat a school breakfast?

NONE 0

ONE 1

TWO 2

THREE 3

FOUR 4

FIVE 5

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

ASK Q.6 IF Q.5=0, 1, OR 2. OTHERS GO TO Q.7

6. Which of the following reasons describe why (CHILD) does not eat school breakfast (more frequently) at school?

INTERVIEWER: READ LIST

PROBE: Is that a reason?

	YES	NO	DON’T KNOW	REFUSED
a. Your child prefers to eat at home?	1	0	d	r
b. You prefer your child to eat breakfast at home?	1	0	d	r
c. There isn’t enough time to eat breakfast at school, for example due to the bus arrival time?	1	0	d	r
d. Your child does not like the food served at school?	1	0	d	r
e. Your child does not like to eat breakfast?	1	0	d	r
f. You thought your child couldn’t participate in the School Breakfast Program?	1	0	d	r
g. Your child doesn’t eat school breakfast because (his/her) friends don’t?	1	0	d	r
h. Your child thinks only needy kids eat school breakfast and (he/she) doesn’t want to be thought of that way?	1	0	d	r
i. You don’t want others to think you can’t provide breakfast for your child?	1	0	d	r
j. Is there any other reason? (SPECIFY)	1	0	d	r
(STRING (NUM))

IF OTHER SPECIFY (99): Insert Other specify statement/question

7. Now I’d like to ask you your opinions about the school breakfast served at (CHILD)’s school. After I read each statement, please tell me if you strongly agree, agree somewhat, disagree somewhat, or strongly disagree.

INTERVIEWER: SKIP ITEMS ‘a’ AND ‘c’ IF CHILD NEVER USUALLY EATS SCHOOL BREAKFAST (Q.5=0).

	STRONGLY AGREE	AGREE SOMEWHAT	DISAGREE SOMEWHAT	STRONGLY DISAGREE	DON’T KNOW	REFUSED
a. Children like the school breakfasts	1	2	3	4	d	r
b. I receive enough information about the School Breakfast Program	1	2	3	4	d	r
c. School breakfasts are served at a convenient time and place	1	2	3	4	d	r
d. School breakfast gives all children an opportunity to eat breakfast	1	2	3	4	d	r
e. Only children from needy families participate in the School Breakfast Program	1	2	3	4	d	r

PROGRAMMER BOX (NUM)

ASK QS. 8-9 IF CHILD EVER EATS SCHOOL BREAKFAST (Q.4=1 OR Q.5 NOT=1, d, or r).

ALL OTHERS GO TO Q.10

8. Would you say the breakfasts served at school are very healthy, somewhat healthy, or not healthy?

VERY HEALTHY 1

SOMEWHAT HEALTHY 2

NOT HEALTHY 3

IT DEPENDS (VOLUNTEERED) 4

DON’T KNOW d

REFUSED r

9. Overall, how satisfied are you with the school breakfast provided at your child’s school? Would you say you are very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?

VERY SATISFIED 1

SOMEWHAT SATISFIED 2

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

DON’T KNOW/CAN’T RATE d

REFUSED r

10. Does (CHILD) ever eat a school lunch, that is a complete lunch provided by the school?

YES 1

NO 0 GO TO Q.12

DON’T KNOW d GO TO Q.12

REFUSED r GO TO Q.12

11. How many days a week does (CHILD) usually eat a school lunch? By school lunch I mean a complete meal such as a fruit or vegetable, sandwich and milk, or a hot meal and milk for free or at a set, fixed price.

NONE, DOESN’T USUALLY EAT SCHOOL LUNCH 0

ONE 1

TWO 2

THREE 3 GO TO Q.13

FOUR 4 GO TO Q.13

FIVE 5 GO TO Q.13

DON’T KNOW d GO TO Q.14

REFUSED r GO TO Q.14

12. Which of the following reasons describe why (CHILD) does not eat school lunch (more frequently) at school?

INTERVIEWER: READ LIST

PROBE: Is that a reason (CHILD) doesn’t eat (more) school lunches?

	YES	NO	DON’T KNOW	REFUSED
a. Your child does not like the food served at school?	1	0	d	r
b. Your child prefers to eat a lunch brought from home?	1	0	d	r
c. You prefer your child to eat foods sent from home?	1	0	d	r
d. Your child eats lunch at home or off campus?	1	0	d	r
e. Your child doesn’t like waiting in lines for lunch?	1	0	d	r
f. Your child doesn’t have enough time to get and eat lunch in school?	1	0	d	r
g. Your child doesn’t eat school lunches because (his/her) friends don’t?	1	0	d	r
h. You thought your child couldn’t participate in the school lunch program?	1	0	d	r
i. Your child doesn’t eat school lunches because they are too expensive?	1	0	d	r
j. Your child doesn’t eat school lunches because (he/she) is a vegetarian or has a special diet?	1	0	d	r
k. Your child thinks only needy kids eat school lunches and (he/she) doesn’t want to be thought of that way?	1	0	d	r
l. Is there any other reason? (SPECIFY)	1	0	d	r
(STRING (NUM))

IF OTHER SPECIFY (99): Insert Other specify statement/question

PROGRAMMER BOX (NUM)

ALL THOSE ANSWERING Q.12, GO TO Q.14

13. What is the main reason (CHILD) eats school lunches?

EASY FOR PARENT 1

CHILD LIKES THE FOOD 2

INEXPENSIVE/FREE/GOOD VALUE 3

HUNGER/WOULDN’T EAT LUNCH OTHERWISE 4

GOOD/HEALTHY MEALS 5

LIKES TO EAT WITH FRIENDS/FRIENDS GET IT 6

EASY FOR THE CHILD 7

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Insert Other specify statement/question

14. Some schools have vending machines where children can purchase snacks, such as chips and cookies, fruit juices and sodas. In many cases, the school receives money from the companies for allowing the machines to be placed in schools. In general, do you think it is a good idea or a bad idea to have vending machines available to students in schools such as the one your child attends?

GOOD IDEA 1

BAD IDEA 2

IT DEPENDS 3

DON’T KNOW/NO OPINION d

REFUSED r

15. Are there any vending machines available to children in (CHILD)’s school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

16. Does your child’s school cafeteria sell foods that children can buy for lunch other than the regular school lunch meal? These might be foods like, hamburgers, French fries, pizza, or ice cream, for example.

YES 1

NO 0

DON’T KNOW d

REFUSED r

17. And does (his/her) school have a school store or snack bar, outside of the cafeteria, where children can buy foods or drinks?

YES 1

NO 0

DON’T KNOW d

REFUSED r

18. Some schools have contracts with national companies such as McDonald’s, Pizza Hut, and Taco Bell, to provide foods for student meals. Do you think it is a good idea or a bad idea to have brand name foods available to students in schools such as the one your child attends?

GOOD IDEA 1

BAD IDEA 2

IT DEPENDS 3

DON’T KNOW/NO OPINION d

REFUSED r

19. Now I would like to ask you your opinions about the school lunches served at (CHILD)’s school. After I read each statement, please tell me if you strongly agree, agree somewhat, disagree somewhat, or strongly disagree.

INTERVIEWER: SKIP ITEMS “a” AND “c” IF CHILD NEVER EATS SCHOOL LUNCH (Q.10=0).

	STRONGLY AGREE	AGREE SOMEWHAT	DISAGREE SOMEWHAT	STRONGLY DISAGREE	DON’T KNOW	REFUSED
a. Children like the school lunches	1	2	3	4	d	r
b. I receive enough information about the School Lunch Program	1	2	3	4	d	r
c. School lunches are served at a convenient time and place	1	2	3	4	d	r
d. School lunch gives all children an opportunity to eat lunch	1	2	3	4	d	r
e. Only children from needy families participate in the School Lunch Program	1	2	3	4	d	r

20. Would you say the lunches served at (CHILD)’s school are very healthy, somewhat healthy, or not healthy?

VERY HEALTHY 1

SOMEWHAT HEALTHY 2

NOT HEALTHY 3

IT DEPENDS 4

DON’T KNOW/NO OPINION d

REFUSED r

21. Thinking about the cost of school lunches and the quality of the meals provided, do you think the school lunches are a very good value, a pretty good value, or not a good value?

VERY GOOD VALUE 1

PRETTY GOOD VALUE 2

NOT A GOOD VALUE 3

GET LUNCH FREE 4

DON’T KNOW/NO OPINION d

REFUSED r

22. Overall, how satisfied are you with the school lunches provided at your child’s school. Would you say you are very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?

VERY SATISFIED 1 GO TO Q.24

SOMEWHAT SATISFIED 2 GO TO Q.24

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

DON’T KNOW/CAN’T RATE d GO TO Q.24

REFUSED r GO TO Q.24

23. Why are you dissatisfied with the school lunches provided by the school?

NOT HEALTHY 1

POOR QUALITY/TASTE 2

NOT ENOUGH CHOICES 3

CHILD WON’T EAT IT 4

POOR PRESENTATION (TEMPERATURE) 5

NOT ENOUGH FOOD/SMALL PORTIONS 6

NOT GOOD VALUE/COST 7

NOT ENOUGH TIME, SCHEDULE 8

STIGMA/CHILD GETS TEASED 9

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Insert Other specify statement/question

24. Did you apply for free or reduced price school meals during the current school year?

YES 1

NO 0

NOT ELIGIBLE – VOLUNTEERED 2

DON’T KNOW d

REFUSED r

25. During the past 30 days, did (CHILD) receive free or reduced price lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

ASK Q.25a ONLY IF SCHOOL HAS A BREAKFAST PROGRAM (Q.1=1)

25a. During the past 30 days, did (CHILD) receive free or reduced price breakfasts at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Now I’d like to ask you some questions about (CHILD).

26. In general, would you say (CHILD)’s health is excellent, very good, good, fair, or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DON’T KNOW d

REFUSED r

27. Do you consider (him/her) to be a very picky eater, a somewhat picky eater, or not a picky eater?

VERY PICKY 1

SOMEWHAT PICKY EATER 2

NOT PICKY 3

DON’T KNOW d

REFUSED r

28. Compared to other (boys/girls) the same age, would you say (CHILD) usually eats a larger amount of food, about the same amount of food, or a smaller amount of food?

LARGER AMOUNT 1

SAME AMOUNT 2

SMALLER AMOUNT 3

DON’T KNOW d

REFUSED r

29. How often does (CHILD) take any vitamins, in pill or liquid form, such as multivitamins or vitamin C? Would you say every day or almost every day, every so often, or not at all?

EVERY DAY OR ALMOST EVERY DAY 1

EVERY SO OFTEN 2

NOT AT ALL 3

DON’T KNOW d

REFUSED r

30. Other than multivitamins with minerals, how often does (CHILD) take (additional) minerals such as calcium or zinc? Would you say every day or almost every day, every so often, or not at all?

EVERY DAY OR ALMOST EVERY DAY 1

EVERY SO OFTEN 2

NOT AT ALL 3

DON’T KNOW d

REFUSED r

31. How often does (CHILD) take any sports supplements or herbal products like Echinacea or alfalfa extract? Would you say every day or almost every day, every so often, or not at all?

EVERY DAY OR ALMOST EVERY DAY 1

EVERY SO OFTEN 2

NOT AT ALL 3

DON’T KNOW d

REFUSED r

32. Does (CHILD) have any food allergies or special dietary needs that affect what (he/she) eats?

YES 1

NO 0

DON’T KNOW d

REFUSED r

33. Thinking now about the foods you serve your family, how often would you say you serve (CHILD) skim milk or 1% low-fat milk? Would you say always or almost always, sometimes, rarely, or never?

ALWAYS OR ALMOST ALWAYS 1

SOMETIMES 2

RARELY 3

NEVER 4

CHILD DOESN’T DRINK MILK—VOLUNTEERED 5

DON’T KNOW d

REFUSED r

34. When (CHILD) eats chicken, how often is it fried? Would you say always or almost always, sometimes, rarely, or never?

ALWAYS OR ALMOST ALWAYS 1

SOMETIMES 2

RARELY 3

NEVER 4

CHILD DOESN’T EAT CHICKEN—VOLUNTEERED 5

DON’T KNOW d

REFUSED r

35. And when (CHILD) eats baked or mashed potatoes, how often do you or your child add butter, margarine, or sour cream? Would you say always or almost always, sometimes, rarely, or never?

ALWAYS OR ALMOST ALWAYS 1

SOMETIMES 2

RARELY 3

NEVER 4

CHILD DOESN’T EAT THIS—VOLUNTEERED 5

DON’T KNOW d

REFUSED r

36. How would you describe the amount of butter, cream cheese, or margarine usually spread on (his/her) breads and muffins? Would you say none, light, moderate, or generous?

NONE 0

LIGHT 1

MODERATE 2

GENEROUS 3

DOESN’T EAT THIS-VOLUNTEERED n

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

Q.37 TO Q.42 IS ASKED OF PARENTS OF CHILDREN ONLY. PARENTS OF YOUTH GO TO Q.43

Thinking now about how your child spends (his/her) free time . . .

37. On an average school day, about how many hours does (CHILD) spend watching TV or DVDs?

INTERVIEWER: IF RANGE GIVEN, TAKE THE MID POINT. ROUND TO NEAREST HALF HOUR.

| | | . | | HOURS (RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Hard check statement/question

38. On an average school day, outside of school, about how many hours does (CHILD) play video or computer games or use a computer for something that is not school work? (Count time spent on things such as Xbox, PlayStation, an iPod, an iPad or other tablet, a Smartphone, YouTube, Facebook or other social networking tools, and the Internet.)

interviewer: IF RANGE GIVEN, TAKE THE MID POINT. ROUND TO NEAREST HALF HOUR.

| | | . | | HOURS (RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Hard check statement/question

39. Now I’d like to ask a question about exercise or other physical activities. Compared to other (boys/girls) the same age, would you say (CHILD) is less active, about as active, more active, or much more active?

LESS ACTIVE 1

ABOUT AS ACTIVE 2

MORE ACTIVE 3

MUCH MORE ACTIVE 4

DON’T KNOW d

REFUSED r

40. During the past 7 days, on how many days was (CHILD) physically active for a total of at least 60 minutes per day? Add up all the time he/she spent in any kind of physical activity that increased his/her heart rate and made him/her breathe hard some of the time. Examples of these activities are competitive sports, running, biking, brisk walking, swimming laps, dancing or pushing a lawn mower.

0 DAYS 0

1 DAY 1

2 DAYS 2

3 DAYS 3

4 DAYS 4

5 DAYS 5

6 DAYS 6

7 DAYS 7

DON’T KNOW d

REFUSED r

41. In a typical week when (CHILD) is in school, on how many days does he/she go to physical education classes?

0 DAYS 0

1 DAY 1

2 DAYS 2

3 DAYS 3

4 DAYS 4

5 DAYS 5

DON’T KNOW d

REFUSED r

42. In a typical week when (CHILD) is in school, on how many days does he/she have recess?

0 DAYS 0

1 DAY 1

2 DAYS 2

3 DAYS 3

4 DAYS 4

5 DAYS 5

DON’T KNOW d

REFUSED r

43. How old was (CHILD) on (his/her) last birthday?

| | | age in years

(NUMBER RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question

44. Do you consider (CHILD) to be of Hispanic or Latino origin, such as Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?

YES/HISPANIC OR LATINO 1

NO/NOT HISPANIC OR LATINO 0

DON’T KNOW d

REFUSED r

45. What race do you consider (CHILD) to be?

PROBE IF RESPONDS “HISPANIC” OR “LATINO”: Would that be White Hispanic/Latino, African-American Hispanic/Latino, or something else?

ASIAN 1

AMERICAN INDIAN OR ALASKA NATIVE 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Insert Other specify statement/question

46. What is the primary language spoken at home with (CHILD)?

ENGLISH 1

SPANISH 2

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Insert Other specify statement/question

Now I’d like to ask you some questions about you and your household.

47. Including you, how many people live in your household?

| | | PEOPLE IN HOUSEHOLD

(NUMBER RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question

48. Of these, how many are under the age of 18?

| | | children

(NUMBER RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question

49. What is your relationship to (CHILD)?

interviewer: READ LIST ONLY IF NECESSARY

MOTHER/FATHER/PARENT 1

PARENT’S SPOUSE OR PARTNER 2

GRANDPARENT 3

OTHER RELATIVE 4

LEGAL GUARDIAN 5

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Insert Other specify statement/question

50. Are you currently living with a partner or spouse?

YES 1

NO 0

DON’T KNOW d

REFUSED r

51. About how many hours a week do you usually spend outside of your home at a paid job, school or job training program?

| | | HOURS PER WEEK (RANGE)

NONE 0

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Hard check statement/question

52. What is the last grade or highest level of education you completed? Is it . . .

8th grade or less, 1

some high school, 2

high school graduate or GED, 3

some college or technical school, 4

Associates or 2 year degree, 5

college graduate or 4 year degree, or 6

graduate school? 7

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

IF Q.50=1, ASK QS. 53-54, OTHERS GO TO Q.55

53. About how many hours a week does your partner or spouse usually spend outside of the home at a paid job, school or job training program?

| | | HOURS PER WEEK (RANGE)

NONE 0

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Hard check statement/question

54. What is the last grade or highest level of education your partner or spouse completed? Is it 8th grade or less, some high school, high school graduate or GED, some college or technical school, Associates or 2 year degree, college graduate or 4 year degree, or graduate school?

8TH GRADE OR LESS 1

SOME HIGH SCHOOL 2

HIGH SCHOOL GRADUATE/GED 3

SOME COLLEGE/TECHNICAL SCHOOL 4

ASSOCIATES/2 YEAR DEGREE 5

COLLEGE GRADUATE/4 YEAR DEGREE 6

GRADUATE SCHOOL 7

DON’T KNOW d

REFUSED r

55. We would like your best estimate of your total annual household income before taxes in the year 2014. Please include all forms of income, including wages, salaries, interest, dividends, and other forms of income such as Social Security, SSI or TANF for all household members.

$ | | | , | | | | record amount (NUMBER RANGE) GO TO Q.59

DON’T KNOW d

REFUSED r

SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question

HARD CHECK: IF CONDITION (e.g. LT 5); Hard check statement/question

56. Is your total household income less than $50,000?

YES 1

NO 0 GO TO Q.58

DON’T KNOW d GO TO Q.59

REFUSED r GO TO Q.59

57. CATI: I’m going to read you some income categories. Please tell me when I read the range that represents your household’s income.

CAPI: Here is a list of income categories, in increasing amounts. Tell me the letter that represents your household’s income.

INTERVIEWER: CAPI: SHOW CARD #1

SHOW

CARD

#1

A. LESS THAN $5,000 1

B. $5,000 TO LESS THAN $10,000 2

C. $10,000 TO LESS THAN $15,000 3

D. $15,000 TO LESS THAN $20,000 4

E. $20,000 TO LESS THAN $25,000 5

F. $25,000 TO LESS THAN $30,000 6

G. $30,000 TO LESS THAN $40,000 7

H. $40,000 TO LESS THAN $50,000 8

DON’T KNOW d

REFUSED r

GO TO Q.59

58. CATI: I’m going to read you some income categories. Please tell me when I read the range that represents your household’s income.

CAPI: Here is a list of income categories, in increasing amounts. Tell me the letter that represents your household’s income.

interviewer: CAPI: SHOW CARD #2

SHOW

CARD

#2

A. $50,000 TO LESS THAN $60,000 1

B. $60,000 TO LESS THAN $70,000 2

C. $70,000 TO LESS THAN $80,000 3

D. $80,000 TO LESS THAN $90,000 4

E. $90,000 TO LESS THAN $100,000 5

F. $100,000 OR MORE 6

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

PROGRAM MUST CALCULATE IF HOUSEHOLD INCOME IS GREATER THAN 200% OF POVERTY, GO TO Q.63

CATI: Next I’d like to know if anyone living in your household currently receives income or benefits from a number of different sources.

CAPI: Please look at this card and tell me if anyone living in your household currently receives income or benefits from any of these sources.

SHOW

CARD

#3

INTERVIEWER: CAPI: SHOW CARD #3 FOR QUESTIONS 59 to 62.

59. Does your household receive SNAP (Supplemental Nutrition Assistance Program) benefits or participate in the Food Distribution Program on Indian Reservations?

CAPI: These are type A on the card.

YES 1

NO 0

DON’T KNOW d

REFUSED r

60. Does your household receive assistance from TANF, Public Assistance, TAFDC, EAEDC, or Welfare?

CAPI: These are type B on the card.

YES 1

NO 0

DON’T KNOW d

REFUSED r

61. Does your household participate in Medicaid, STATE HEALTH, or SCHIP?

CAPI: These are type C on the card.

YES 1

NO 0

DON’T KNOW d

REFUSED r

62. Does anyone in your household receive benefits under the WIC Program—Women, Infants and Children Program?

CAPI: This is type D on the card.

YES 1

NO 0

DON’T KNOW d

REFUSED r

63. Which of these statements best describes the food eaten in your household in the last 30 days: we have enough of the kinds of food we want to eat; enough, but not always the kinds of food we want; sometimes not enough to eat; or often not enough to eat?

ENOUGH OF THE KINDS OF FOOD WE WANT TO EAT 1

ENOUGH BUT NOT ALWAYS THE KINDS OF FOOD WE WANT 2

SOMETIMES NOT ENOUGH TO EAT 3

OFTEN NOT ENOUGH 4

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

IF Q.63=1 AND HOUSEHOLD INCOME IS ABOVE TWICE THE POVERTY THRESHOLD (SEE GRID BELOW), GO TO Q.83

IF Q.63=1 AND HOUSEHOLD INCOME IS BELOW TWICE THE POVERTY THRESHOLD (SEE GRID BELOW), OR INCOME IS DON’T KNOW OR REFUSED (Q.57 OR Q.58a OR Q.58b), ASK Q.64

Poverty Threshold Measure: ASK Q.64 IF . . .
If household size is . . .	And answer to Q.58a is . . .	Or answer to Q.58b is . . .
1	A-D	-
2	A-E	-
3	A-F	-
4	A-G	-
5	A-G	-
6	A-H	-
7	-	A
8	-	A
9	-	A or B
10	-	A or B

Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months, that is, since last (FILL NAME OF CURRENT MONTH).

64. The first statement is, (I/we) worried whether (my/our) food would run out before (I/we) got money to buy more. Was that often true, sometimes true, or never true for (you/your household) in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

65. “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 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

66. “(I/we) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q.67 AND Q.68; OTHERWISE GO TO FIRST LEVEL SCREEN

67. “(I/we) relied on only a few kinds of low-cost food to feed (my/our) (child/the children) because (I was/we were) running out of money to buy food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

68. “(I/we) couldn’t feed (my/our) (child/the children) a balanced meal because (I/we) couldn’t afford that.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

FIRST LEVEL SCREEN (Screener for Stage 2): IF AFFIRMATIVE RESPONSE TO ANY ONE OF QUESTIONS 64-68, (i.e., “often true” or “sometimes true”), OR RESPONSE “3” OR “4” TO QUESTION 63 (if administered), THEN CONTINUE TO STAGE 2; OTHERWISE GO TO Q.80.

STAGE 2 QUESTIONS 69-73: ASK HOUSEHOLDS PASSING THE FIRST LEVEL SCREEN (estimated 40 percent of households < Poverty; 5.5 percent of households > Poverty; 19 percent of all households).

IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q.69; OTHERWISE GO TO Q.70

69. “(My/our child was/the children were) not eating enough because (I/we) just couldn’t afford enough food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

70. In the last 12 months, since last (FILL NAME OF CURRENT MONTH), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn’t enough money for food?

YES 1

NO 0 GO TO Q.71

DON’T KNOW d GO TO Q.71

REFUSED r GO TO Q.71

70a. How often did this happen-almost every month, some months but not every month, or in only one or two months?

ALMOST EVERY MONTH 1

SOME MONTHS, BUT NOT EVERY MONTH 2

ONLY ONE OR TWO MONTHS 3

DON’T KNOW d

REFUSED r

71. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

72. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

73. In the last 12 months, did you lose weight because you didn’t have enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

SECOND LEVEL SCREEN (Screener for Stage 3): IF AFFIRMATIVE RESPONSE TO ANY ONE OF QUESTIONS 69 THROUGH 73, THEN CONTINUE TO STAGE 3; OTHERWISE GO TO Q.80.

STAGE 3 QUESTIONS 74 THROUGH 79: ASK HOUSEHOLDS PASSING THE SECOND LEVEL SCREEN (estimated 7-8 percent of households < 185 percent poverty; 1-1.5 percent of households > 185 percent poverty; 3‑4 percent of all households).

74. In the last 12 months, did (you/other adults in your household) ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 0 GO TO Q.76

DON’T KNOW d GO TO Q.76

REFUSED r GO TO Q.76

75. How often did this happen-almost every month, some months but not every month, or in only one or two months?

ALMOST EVERY MONTH 1

SOME MONTHS, BUT NOT EVERY MONTH 2

ONLY ONE OR TWO MONTHS 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK QUESTIONS 76 THROUGH 79; OTHERWISE GO TO Q.80

76. The next questions are about children living in the household who are under 18 years old. In the last 12 months, since (FILL CURRENT MONTH) of last year, did you ever cut the size of (your child’s/any of the children’s) meals because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

77. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals because there wasn’t enough money for food?

YES 1

NO 0 GO TO Q.78

DON’T KNOW d GO TO Q.78

REFUSED r GO TO Q.78

77a. How often did this happen-almost every month, some months but not every month, or in only one or two months?

ALMOST EVERY MONTH 1

SOME MONTHS, BUT NOT EVERY MONTH 2

ONLY ONE OR TWO MONTHS 3

DON’T KNOW d

REFUSED r

78. In the last 12 months, (was your child/were the children) ever hungry but you just couldn’t afford more food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

79. In the last 12 months, did (your child/any of the children) ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

80. Did you or another member of your household receive groceries from a food pantry in the last 30 days? Include groceries delivered to your household by the food pantry.

YES 1

NO 0

DON’T KNOW d

REFUSED r

81. Did you or another member of your household receive one or more meals from a soup kitchen, mobile van, or food wagon in the last 30 days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

82. Did you or another member of your household spend one or more nights in the past 30 days in a shelter?

YES 1

NO 0

DON’T KNOW d

REFUSED r

CLOSING Those are all of the questions I have for you. Thank you for your time.

INTERVIEWER: FOR PARENTS OF CHILDREN: GIVE GIFT CARD.

FOR PARENTS OF YOUTHS: GET/CONFIRM ADDRESS TO MAIL THANK YOU CHECK.

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r