Team Nutrition Educational Materials for Summer Meals

Generic Clearance to Conduct Formative Research

20150224 Attachment A Screener for ParentCaregivers - English

Team Nutrition Educational Materials for Summer Meals

OMB: 0584-0524

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OMB Control # 0584-0524 | Expiration: 06/30/2016 |Page 1


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Attachment A: Screener for Parents/Caregivers (English Version)


Please choose the option that best answers each question for you.


  1. Are you the parent or guardian of any children who live at home with you?

( ) yes

( ) no


  1. How many children are there in your home for whom you are the parent or legal guardian? ______________


  1. How old are each of these children?

    1. Child #1________

    2. Child #2________

    3. Child #3________

    4. Child #4________

    5. Child #5­________

    6. Child #6________


  1. Federal Poverty Level Adjusted for Household Size (see Table 3).

    1. What is the size of your household (Including yourself) ____________

    2. Table 4 Internal Use Only – Income Threshold for Participation

      Household Size

      Maximum Annual

      Household Income

      1

      $21,589.00

      $29,100.00

      $36,611.00

      $44,122.00

      $51,633.00

      $59,144.00

      $66,655.00

      $74,166.00

      2

      3

      4

      5

      6

      7

      8

      What is your annual household income _____________


  1. What is your gender

( ) Male

( ) Female


  1. What is your primary language? ________________________


  1. Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino


  1. Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White


  1. What is your country of origin? _______________________


  1. Does anyone in your household work in any of the following industries?

( ) Nutrition/Food Service

( ) Fitness

( ) Food manufacturing

( ) School Food Service

( ) Food/Nutrition Assistance Programs


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGerad O'Shea
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File Created2021-01-27

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