Revised - Individuals/Households - Preparation for the Launch of the Summer Meals Study

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

APPENDIX E-4. Household Eligibility Screener

WEB SCREENER

1. How many children 18 years or younger live in your household?

____ Children

By household, we mean people who live with you and with whom you purchase and prepare food. Please include children who usually live in your household but may be temporarily away and children who are living with you temporarily.

2. Of these, how many children have attended/plan to attend a summer program this year?

None of my children have attended or will attend a summer program this year  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY. PLEASE CLICK HERE TO BEGIN THE SURVEY NOW.

____ Children  GO TO QUESTION 3

3. IF 1 OR MORE: Will any of these children be attending the summer program at <SITE NAME> this year?

Yes  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY. PLEASE CLICK HERE TO BEGIN THE SURVEY NOW.

No  GO TO QUESTION 4

4. IF 1 or more children has attended or plans to attend a summer program but not at <SITE NAME>: Does the summer program provide your child: (CHECK ONLY ONE)

Meals and snacks are not provided  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY. PLEASE CLICK HERE TO BEGIN THE SURVEY NOW.

Meals and snacks for a fee  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY. PLEASE CLICK HERE TO BEGIN THE SURVEY NOW.

Meals and snacks at no cost  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Meals and snacks are a part of the program fee  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Not sure  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

PHONE SCREENER

1. How many children 18 years or younger live in your household?

____ Children

By household, we mean people who live with you and with whom you purchase and prepare food. Please include children who usually live in your household but may be temporarily away, and children who are living with you temporarily.

2. Of these, how many children have attended/plan to attend a summer program this year?

None of my children have attended or will attend a summer program this year  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

____ Children  GO TO QUESTION 3

3. IF 1 OR MORE: Will any of these children be attending the summer program at <SITE NAME> this year?

Yes  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

No  GO TO QUESTION 4

4. IF 1 or more children has attended or plans to attend a summer program but not at <SITE NAME>: Does the summer program provide your child: (CHECK ONLY ONE.)

Meals and snacks are not provided  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Meals and snacks for a fee  YOU ARE ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Meals and snacks at no cost  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Meals and snacks are a part of the program fee  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

Not sure  THANK YOU FOR COMPLETING THE SCREENER. YOU ARE NOT ELIGIBLE TO TAKE PART IN THE SUMMER MEALS STUDY.

FOR ALL ELIGIBLE RESPONDENTS

You may complete the web survey or request a paper copy of the survey. For instructions on how to complete the web survey, press 1 now. To request a paper survey in the mail, press 2 now.

PRESS 1 for instructions on how to complete the web survey: Please login to the secure study website and log in using the PIN provided to you in the invitation letter. It is the same PIN that you used to complete this brief phone survey.

PRESS 2 for paper survey: Thank you. We will mail a paper survey to you at (ADDRESS ON FILE).

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 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 Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.