SNAP E&T Program Participants (Individuals/Households) Respondents

_Appendix A-6c. Web Survey of SNAP and Work--English

MONTH, DAY, YEAR (Insert date after OMB clearance)

Welcome

WELCOME SCREEN

OMB Control No. 0584-0606

Expiration Date: 03/31/2019

Welcome to the Survey of SNAP and Work! To begin the survey, enter your PIN and click on the “Continue” button.

Public reporting burden for this collection of information is estimated to average 30 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 (0584-0606). Do not return the completed form to this address.

Privacy Act Statement

Authority: Section 9 of the Food and Nutrition Act of 2008, as amended, (7 U.S.C. 2018); section 205(c)(2)(C) of the Social Security Act (42 U.S.C. 405(c)(2)(C)); and section 6109(f) of the Internal Revenue Code of 1986 (26 U.S.C. 6109(f)), authorizes collection of the information on this application.

Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration of the Supplemental Nutrition Assistance Program;

Routine Use: Information may be disclosed for any of the routine uses listed in the published System of Record  notice https://www.federalregister.gov/documents/2010/12/27/2010-32457/privacy-act-revision-of-privacy-act-systems-of-records#p-30

Disclosure: Furnishing the information on this form is voluntary.

Introduction

INTRODUCTION SCREEN

You have been selected to take part in the Survey of SNAP and Work! Westat is conducting this study on behalf of the U.S. Department of Agriculture’s Food and Nutrition Service. The survey will ask about your employment experience and challenges faced in finding and keeping employment. The results will help states understand the needs and challenges of people who receive benefits from the Supplemental Nutrition Assistance Program, also called SNAP, or known as [STATE NAME FOR SNAP] in your State.

This web survey should take on average about 30 minutes to complete. As an incentive, and to offset any cost incurred by your participation, we will send you [FILL $ 40 FOR IN-PERSON] in cash.

Your participation in this survey is completely voluntary. Please know that your responses will be kept private, except as otherwise required by law, and will not be shared with your SNAP eligibility worker or anyone else not involved with conducting the study. Neither your name nor any other information about your identity will be used in any reports. The information you provide will be combined with information from everyone who participates in the study. You may skip any question that you prefer not to answer. If you decide not to participate, there will be no loss of benefits. As described in the system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports (published in the Federal Register on April 25, 1991, volume 56, pages 19078-19080), FNS and contractors working on their behalf may collect and analyze this information for research purposes and are required to have safeguards in place to keep data private.

HOW TO COMPLETE THE SURVEY: After you complete each question, you may go to the next by clicking on the “Next>>” button. If you wish to review a previous answer, click on the “<<Previous” button. If you need to save your responses and complete the survey later, click on the “Save and Continue Later” button. When you log on later, you can continue where you left off.

IF YOU HAVE QUESTIONS ABOUT YOUR RIGHTS AND WELFARE AS A RESEARCH PARTICIPANT: Please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about “Survey of SNAP and Work”, and a telephone number beginning with the area code. Someone will return your call as soon as possible.

To begin the survey, click the “Next>>” button. Doing so also indicates your consent to participate in the survey.

Section A: Demographic Characteristics

This section asks questions about you.

1. What is your month and year of birth?

Month

4-digit Year

2. What is your sex?

• Male

• Female

3. Are you Hispanic or Latino?

• Yes, Hispanic or Latino

• No, not Hispanic or Latino

• Don’t know

4. Below is a list of five race categories. You may choose one or more races. For this survey, Hispanic origin is not a race. What is your race?

(Check all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

5. Are you married, widowed, divorced, separated or never married?

• Married

• Widowed

• Divorced

• Separated

• Never married

6. Did you ever serve on active duty in the U.S. Armed Forces?

• Yes

• No [SKIP TO A8]

7. Are you currently on active duty in the Armed Forces?

• Yes

• No

8. What is the highest level of school you have completed or the highest degree you have received?

• 12th grade or less – NO DIPLOMA

• High school equivalent such as GED

• High school diploma

• Some college but no degree

• Associate degree in college - Occupational/vocational program (for example, an Associate of Applied Science, such as Accounting, Business Administration, Nursing, Web Design, or Paralegal Studies)

• Associate degree in college - Academic program (such as Associate of Arts or Associate of Science)

• Bachelor's degree (e.g., BA, AB, BS)

• Master’s degree (e.g., MA, MS, MBA); Professional school degree (e.g., MD, DDS, JD); OR Doctorate degree (e.g., PhD, EdD)

9. Currently, do you have an active professional certification or a state or industry license? Do not include a business license, such as a liquor license or vending license. (A professional certification or license shows you are qualified to perform a specific job. Examples include a real estate license, a medical assistant certification, a Teacher License or an IT certification).

• Yes

• No ➔ [SKIP T0 A11]

10. What type of certification or license is this (if more than one, list the two most recent)?

11. Do you speak a language other than English at home?

• Yes

• No ➔ [SKIP TO SECTION B]

12. What is this language?

13. How well do you speak English?

• Very well

• Well

• Not well

• Not at all

Section B: Employment

The questions in this section ask about all the jobs you’ve held since [Sample month – 6]. We’ll first ask about your current or most recent job. Then, we’ll ask about any other jobs you’ve held since [Sample month – 6].

1. Have you ever worked for pay since [Sample month - 6]? Please be sure to include part-time jobs, odd jobs, self-employment, work you do as an independent contractor or free-lance worker, or other work you have done for pay since [Sample month - 6].

• Yes

• No ➔ [SKIP TO B2]

[if B1=yes]

B1a. How many separate jobs in total have you had since [Sample month -6]

_____________ jobs [SKIP TO B3]

• Don’t know [SKIP TO B1b]

[if B1a=DK]

B1b. About how many jobs was it? About how many jobs have you had since [Sample month - 6]?

• 1 or 2 jobs

• 3 or 4 jobs

• 5 to 7 jobs

• 8 to 10 jobs

• More than 10 jobs

[SKIP TO B3]

2. Have you ever worked for pay any time before [Sample month - 6]?

• Yes

• No [SKIP TO B30]

B2a. When did you last work for pay?

Month

4 Digit Year

• Don’t know

[If B2a MMYYYY is given, SKIP TO B30; if B2a is DK, ASK B2b]

B2b. About how long ago have you last worked? Did you last work…

• 1 or 2 years ago

• More than 2 years ago but less than 5 years

• More than 5 years ago

[SKIP to B30]

3. Are you currently working at a job for pay?

• Yes

• No➔ [SKIP TO B7]

4. Now let’s talk about LAST WEEK. LAST WEEK, did you have more than one job, including a part time, evening or weekend job?

• Yes

• No ➔ [SKIP TO B7]

5. Altogether, how many jobs did you have last week?

• 2 jobs

• 3 jobs

• 4 or more jobs

6. How many hours per week do you USUALLY work at all your jobs combined?

Hours per week

• Hours vary each week

[If B6=Hours vary each week, ask B6a]

B6a. Counting all your jobs, about how many hours would you say you usually worked in a week during the past month?

• 1 to 14 hours per week

• 15 to 29 hours per week

• 30 to 34 hours per week

• 35 to 40 hours per week

• More than 40 hours per week

7. The next questions are about [your current job/the job you worked the most hours at last week/the job you had most recently]. What kind of work do/did you do, that is, what (is/was) your occupation? For example: plumber, typist, farmer.

8. What is/was the name of your employer? Or were you self-employed?

Name of employer

• Self-employed

9. What kind of business or industry (is/was) this? What (do/does/did) (the employer/you) make or do?

10. When did you start working at this job?

Month

4 Digit Year

• Don’t know

[if B3=No, not currently working, ask B11; if B3=Yes, SKIP TO B12]

11. When did you stop working at this job?

Month

4 Digit Year

• Don’t know

[if B11=DK, ask B11a; otherwise, SKIP TO B11b]

B11a Approximately when did you stop working at this job? Was it…

• Within the past month

• 1 to 2 months ago

• 3 to 5 months ago

• More than 5 months ago

• Don’t know

B11b Why did you stop working? If there is more than one reason, please select the MAIN reason you stopped working:

• Layoff or plant closing

• End of temporary or seasonal job

• Discharged or fired

• Pregnancy or birth of a child

• Other family reason

• Poor health

• Quit to look for another job

• Returned to school or devote more time to school

• Moved away from the job

• Transportation problems

• Some other reason. Please specify

12. How many hours per week (do/did) you usually work on this job?

Hours per Week

• Don’t know

[if B12= DK, ask B13; otherwise, SKIP TO instruction before B14]

13. About how many hours (do/did) you work at this job in a typical week?

• 1 – 14 hours

• 15 – 29 hours

• 30 – 34 hours

• 35 – 40 hours

• More than 40 hours

• Don’t remember

[if B12 < 35 or B13= (1, 2, 3), ask B14; otherwise, SKIP TO B16]

14. (Do/did) you want to work a full-time workweek of 35 hours or more?

• Yes

• No [SKIP TO B16]

15. Some people work part time because they cannot find full time work or because business is poor. Others work part time because of family obligations or other personal reasons. What (is/was) your MAIN reason for working part time at this job? (Select only one)

• My hours were cut

• Could only find part-time work

• Seasonal work

• Child care problems

• Other family/personal obligations

• Health/medical limitations

• School/training

• Retired/Social Security limit on earnings

• Other (Please specify):

B15a. Was there another important reason for working part-time? Select one response to denote your second most important reason, or select “There was no other reason.”

• My hours were cut

• Could only find part-time work

• Seasonal work

• Child care problems

• Other family/personal obligations

• Health/medical limitations

• School/training

• Retired/Social Security limit on earnings

• Other (Please specify):

• There was no other reason

16. How (do/did) you usually get to work at this job? If you usually (use/used) more than one method of transportation during the trip, select the one used for most of the distance.

• Personal vehicle, such as my or my family’s car, truck, van or motorcycle

• Rode with a friend, family member, or co-worker

• Public transportation, such as bus, trolley, streetcar, subway, ferry, or railroad

• Taxicab

• Bicycle

• Walked

• Worked at home

• Other method

17. How many minutes (does/did) it usually take you to get to work? Please count time only for a one-way trip.

Minutes

18. How much (are / were) you earning (at / when you left) this job and what is the schedule for receiving the pay? Please include tips, commissions, bonuses, and regular overtime.

Amount

• Hourly

• Weekly

• Every two weeks

• Monthly

• Yearly

• Other specify ______________

• Don’t know ➔ [SKIP TO B18c]

[If amount is given in B18, ask B18a; if B18=Don’t Know, SKIP TO B18c]

B18a. Is that amount before, or after, taxes and other deductions?

• Before taxes and other deductions➔ [SKIP TO B19]

• After taxes and other deductions

• Don’t know➔ [SKIP TO B19]

[If B18a=After taxes and deductions, ask B18b; otherwise, skip to B19]

B18b. How much was it before taxes and other deductions.

Amount

• Hourly

• Weekly

• Every two weeks

• Monthly

• Yearly

• Other specify ______________

• Don’t know

[SKIP TO B19]

[If B18=Don’t Know, ask B18c]

B18c. Which of the following ranges best describes the approximate amount you earned at this job during a typical week?

• Less than $100 per week

• $100 to $250 per week

• $251 to $500 per week

• $501 to $750 per week

• More than $750 per week

• Don’t remember

19. Which of the following best describes your work schedule at this job?

• Regular daytime shift (working any time between 6am and 6pm with the same or similar schedule week to week)

• Regular evening shift (working any time between 6pm and 6am with the same or similar schedule week to week)

• Rotating shift (one that changes regularly from days to evenings to nights)

• Split shift (one consisting of two distinct periods each day)

• An irregular schedule (one that changes from day to day or week to week)

20. How would you describe your work at this job? Please check “YES” or “NO” to each item.

	YES	NO
a. A regular permanent job		
b. Self-employed/work you do for your own business		
c. Seasonal work, meaning you were hired for only a few weeks or months		
d. Work for a “temp” agency or staffing agency		
e. An occasional odd job, meaning you were hired for only a few hours or days and you did not expect it to turn into anything more than that		
f. Work as an independent contractor or free-lance worker		
g. Work you do for a friend or family member		
h. Something else		

21. (Are/Were) any of the following benefits available to you at this job?

	YES	NO
a. Sick days with full pay		
b. Paid vacation		
c. Paid holidays, such as Christmas and New Year’s Day		
d. Dental benefits		
e. A health plan or medical insurance		
f. A retirement or 401K plan		
g. Tuition reimbursement		

[IF B21E=YES, ask B22; otherwise, SKIP TO B23]

22. (Are/Were) you enrolled in the health insurance plan at this job?

• Yes

• No

23. Have you worked at another job for pay since [Sample Month - 6]?

• Yes

• No ➔ [SKIP TO instruction preceding B30]

[if B23= Yes]

The next questions are about the job that you had prior to the one you just described.

24. What is the name of your employer at this job? Or were you self-employed?

Name of employer

• Self-employed

25. When did you start working at this job?

Month

4 Digit Year

• Don’t know

26. When did you stop working at this job?

Month

4 Digit Year

• Don’t know

• Hasn’t ended yet

27. How many hours per week did you usually work on this job?

Hours worked per week

• Don’t know

[if B27= Don’t know, ask B28; otherwise, SKIP TO B29]

28. About how many hours did you work at this job in a typical week?

• 1 – 14 hours

• 15 – 29 hours

• 30 – 34 hours

• 35 – 40 hours

• More than 40 hours

• Don’t remember

29. How much were you earning when you left this job? Please include tips, commissions, bonuses, and regular overtime.

Amount

• Hourly

• Weekly

• Every two weeks

• Monthly

• Yearly

• Don’t remember ➔ [SKIP TO B29c]

[If amount is given in B29, ask B29a; if B29=Don’t Know, SKIP TO B29c]

B29a. Is that amount before, or after, taxes and other deductions?

• Before taxes and other deductions➔ [REPEAT B23-B29 FOR ALL PREVIOUS JOBS GOING BACK TO SAMPLEMONTH – 6]

• After taxes and other deductions ➔ [ASK B29b]

• Don’t know➔ [REPEAT B23-B29 FOR ALL PREVIOUS JOBS GOING BACK TO SAMPLEMONTH - 6]

[If B29a=After taxes and deductions, ask B29b

B29b. How much was it before taxes and other deductions?

Amount

• Hourly

• Weekly

• Every two weeks

• Monthly

• Yearly

• Other specify ______________

• Don’t know

[REPEAT B23-B29 FOR ALL PREVIOUS JOBS GOING BACK TO SAMPLEMONTH – 6]

[If B29a=Don’t Know, ask B29c]

B29c Which of the following ranges best describes the approximate amount you earned at this job during a typical week?

• Less than $100 per week

• $100 to $250 per week

• $251 to $500 per week

• $501 to $750 per week

• More than $750 per week

• Don’t remember

[REPEAT B23-B29 FOR ALL PREVIOUS JOBS GOING BACK TO SAMPLEMONTH - 6]

[If B1=No or B3=No then ask B30; otherwise SKIP TO SECTION C]

30. What is the main reason you are not currently working?

• Pregnant or recent birth of a child

• Ill or disabled

• Retired

• Taking care of home or family

• Going to school or in a job training program

• Could not find work

• Other
  Please specify _________________________

31. During the LAST 4 WEEKS, have you been ACTIVELY looking for work?

• Yes

• No ➔ [SKIP TO C1]

32. LAST WEEK, could you have started a job if offered one?

• Yes

• No

33. Are you currently receiving any State or Federal unemployment compensation?

• Yes

• No

Section C. Education, Training and Employment Services

The questions in this section ask about education, training and employment services you might have received in the last 12 months; that is, since [mmddyyyy]

1. First, we would like to know if you attended any education program (high school, adult basic education, or college) or job training program since [mmddyyyy]. Have you been enrolled in any school or job training program since [mmddyyyy]?

• Yes

• No [SKIP TO C3]

• Don’t know [SKIP TO C3]

C2. How many education or training programs did you participate in since [mmddyyyy]?

Number of programs

C3. Are you currently enrolled in an education or training program?

• Yes

• No [SKIP TO C13 if C2=0; if C2 > 0 GO to C4]

• Don’t know [SKIP TO C13]

4. Where (do/did) you participate in that education or training? (Was/Is) it at…

• A high school

• A community college or 2-year college

• A 4-year college or university

• A vocational, technical or business school

• A private company that provides training (may include your employer)

• Joint apprenticeship training program (union affiliated)

• A community agency

• Or somewhere else

  • Where (do/did) you participate in that education or training?

• Don’t know

4. In what month and year did you start that education or training?

Month

4 Digit Year

• Don’t know

[SKIP to C7 if C3 = yes]

4. In what month and year did you stop attending that education or program?

Month

4 Digit Year

• Don’t know

[SKIP TO C8 if C3>0]

4. In what month and year do you expect to stop attending that education or program?

Month

4 Digit Year

• Don’t know

4. How many hours per week (do/did) you attend this education or training program?

Hours per week

• Don’t know

4. (Are/were) you being trained in some skill or occupation, or (are/were) you taking a general education program?

• General education [SKIP TO C11]

• Skill or occupation

• Don’t know [SKIP TO C11]

4. What kind of work (are/were) you being trained for? For example, education, health, or marketing.

• Agriculture and natural resources

• Business management and support (such as business administration, accounting and secretarial)

• Communication and design

• Computer and informational sciences (such as programming, data processing, computer networks)

• Construction trades

• Consumer or personal services (such as culinary services, cosmetology, and fitness studies)

• Education

• Engineering and science technologies

• Health (such as dental support, medical assistant, physical therapy, nursing, and medical diagnostics)

• Marketing

• Manufacturing

• Mechanics and repair

• Protective services (including criminal justice and other protective services)

• Transportation and material moving

• Other
  specify ________________________

• Don’t know

4. Did you complete that education or program?

• Yes

• No [SKIP TO C13]

• Don’t know

4. Did you receive a degree, certificate, or license from completing that program?any of the followingthrough participating in this education or program?

• Yes

• No

• Don’t know

4. In the last 12 months, have you received any of the following types of employment services?

	YES	NO	DON’T KNOW
a. Career counseling including tests to see what jobs you were suited for, information about education or job training programs, information on how to change careers, or information about what jobs are available in your local area?			
b. Job search assistance including assistance in searching for work, referrals to jobs or employers, or providing labor market information?			
c. Job readiness training including help filling out an application, writing a resume, or going for an interview?			
d. Workfare or community service			

[If at least one YES is checked in C13, ask C14; otherwise SKIP TO SECTION D]

4. Who provided the most recent employment services you received? Was it…

• American Job Center office (or Employment Service office)

• State Unemployment Insurance office

• Another government agency

• A community agency

• My employer

• A school, college or university

• A placement agency

• Other
  Specify ____________________________

• Don’t know

Section D. Barriers to Employment

These next questions are about items people view as barriers or obstacles to securing jobs. Remember that your responses will be protected and kept private.

1. Do you have a physical, emotional, or other health condition that limits the amount or type of work you can do?

• Yes

• No [SKIP to D3]

• Don’t know [SKIP TO D3]

2. What kind of work-limiting health problems do you have? Do you have…

	YES	NO	DON’T KNOW
A physical disability, injury or illness?			
An emotional or mental health problem?			
A learning disability?			
Some other work-limiting health problem? IF YES: What is that health problem?			

3. Have you ever been convicted or pled guilty to a felony?

• Yes

• No [SKIP TO D7]

• Don’t know [SKIP TO D7]

4. In what month and year was your last felony conviction?

Month

4-digit Year

• Don’t Know

5. Did you ever spend time in prison or jail?

• Yes

• No [SKIP TO D7]

• Don’t know [SKIP TO D7]

6. About how long ago were you released from prison or jail? If you were incarcerated more than once, when were you most recently released? Was it…

• Less than 1 year ago

• 2 to 5 years ago

• More than 5 years ago

• Don’t know

• D7. For each statement, please tell me how much it affects your securing a job by giving me a number from 1 to 5 where 1 means not a barrier for you to secure a job and 5 means a strong barriers for you to secure a job

	Not a barrier 1	2	3	4	Strong barrier 5
1. Having less than a high school education					
2. Work limiting health condition (illness/injury)					
3. Lack of adequate job skills					
4. Lack of job experience					
5. Lack of transportation					
6. Lack of child care					
7. Racial discrimination					
8. Lack of information about jobs					
9. Lack of stable housing					
10. Drug/alcohol addiction					
11. Domestic violence					
12. Physical disabilities					
13. Mental illness					
14. Fear of rejection					
15. Lack of work clothing					
16. No jobs available in the community					
17. No jobs available that match your skills/training					
18. Being a single parent					
19. Need to take care of young children or other person in your household					
20. Cannot speak English very well					
21 Cannot read or write very well					
22. Problems with getting to job on time					
23. Lack of confidence					
24. Lack of support system					
25. Lack of adequate coping skills for daily struggles					
26. Anger management					
27. Past criminal record					

Section E: SNAP Participation

This section asks questions about your use of the Supplemental Nutrition Assistance Program (SNAP), formerly called Food Stamps, or known as [State Name for SNAP] in your State.

1. Are you currently receiving any SNAP benefits?

• Yes

• No ➔ [SKIP TO E3]

2. Did you receive SNAP CONTINUOUSLY, every month since [Sample Month]?

• Yes ➔ [SKIP TO E7]

• No ➔ [SKIP TO E6]

• Don’t know➔ [SKIP TO E6]

3. Since [Sample Month], did you receive any SNAP benefits?

• Yes

• No ➔ [SKIP to SECTION F]

• Don’t know➔ [SKIP SECTION F]

4. What month and year did you last receive SNAP benefits?

Month

Please Select▼

4 Digit Year

Please Select▼

• Don’t know

5. Why did you stop receiving SNAP? Please check all that apply?

• Became ineligible because of increased income

• Became ineligible because of family changes (e.g. family member moved out of household)

• Became ineligible because program rules or requirements were not met (did not attend school, job training, etc.)

• Eligibility ran out because of time limits

• Still eligible but chose not to participate

• Other (Please specify):

Please Select▼

6. For how many months since [Sample Month] did you receive SNAP benefits?

Months

• Don’t know

7. In the last 12 months, did you participate in an employment and training program as part of receiving SNAP benefits? Please select the answer that best describes your experience.

• Yes, I volunteered to participate

• Yes, I participated because it was required to keep SNAP benefits

• No, I was told I had to participate, but I didn’t do it ➔ [SKIP TO E9]

• No, I never got told I had to participate and didn’t volunteer ➔ [SKIP TO E9]

• No, I participated in the past but not in the last 12 months ➔ [SKIP TO E9]

8. Are you still attending the program, or have you completed it?

• Still attending the program

• Left before the end of the program

• Completed the program

9. Did the state agency that is responsible for your SNAP benefits require you to register for work with the state workforce agency?

• Yes

• No

• Don’t know

Section F. Health and Health Insurance

These next few questions ask about your health insurance coverage.

1. Do you have health insurance coverage?

• Yes

• No➔ [SKIP TO F3]

• Don’t know➔ [SKIP TO F3]

2. What type of health insurance or health coverage do you have? If you are covered by more than one type, please select the type that covers most of your expenses.

• Insurance through a current or former employer or union (by you or another family member)

• Insurance purchased directly from an insurance company (by you or another family member)

• Medicare, for people 65 and older, or people with certain disabilities

• Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability

• TRICARE or other military health care

• VA (including those who have ever used or enrolled for VA health care)

• Indian Health Service

• Don’t know

• Any other type of health insurance or health coverage plan. (Please specify):

3. In general, would you say your health is…

• Excellent

• Very good

• Good

• Fair

• Poor

Section G: Household Information

This section asks for information about where you live and who you live with.

1. In what type of place are you currently living?

• I own my own home (including mobile home)

• I rent my home or apartment (including mobile home)

• I live at the home of family or friends without paying rent

• I live at the home of family or friends paying reduced rent

• I live in emergency or temporary housing (e.g., in a shelter or is homeless)

• Something else? (Please specify):

The next questions are about people in your household. By household we mean a group of people who live together and purchase food and prepare meals together. A household may also be a person who lives alone or who, while living with others, customarily buys food and prepares meals separate and apart from the others. Please count only yourself if you live in a dormitory, other institution or a hospital, or you prepare your meals separate and apart from others.

2. How many people, including yourself, are in your household?

[if G2 > 1, ask G3; otherwise, SKIP TO G5]

3. For each member of your household other than yourself, please complete the following information.

First Name	Relationship to you	Age
	Please Select▼	Please Select▼
HH Member 2
HH Member 3
HH Member 4
HH Member 5
HH Member 6
HH Member 7

[for G3 dropdown: Relationship to you]

• Spouse or Unmarried Partner

• Child

• Grandchild

• Parent (Mother/Father)

• Brother/Sister

• Other relative (Aunt, Cousin, Nephew, Mother-in-law, etc.)

• Foster Child

• Housemate/Roommate

• Other nonrelative

[Instruction: autofill first names of persons ages 16 or older from hh roster above]

4. Please complete the following information for people in your household 16 years old or older.

First Name	Is this person currently employed?	If employed, how many hours does he/she usually work per week at all jobs?	Is this person on Active Duty in the Armed Forces?
	Please Select▼	Please Select▼	Please Select▼
Adult 1
Adult 2
Adult 3
Adult 4
Adult 5

[for G4 dropdown: Is this person currently employed]

• Currently employed

• Not employed but looking for work

• Not employed and not looking

[for G4 dropdown: If employed, how many hours does he/she usually work per week at all jobs]

• Usually works 35 or more hours per week

• Usually works 20 to 34 hours per week

• Usually works 1 to 19 hours per week

[for G4 dropdown: On active duty in the Armed Forces]

• Yes

• No

[Ask G5 if G1 is not “I live in emergency or temporary housing”; otherwise, SKIP TO next section]

5. Where you currently live, do you or any member of this household have access to the Internet?

• Yes

• No

Section H: Dependents and Dependent Care

[Question H1 will be programmed so that it is only asked if respondent indicated in the household characteristics section that there are children under age 13 in their household.]

1. You indicated that there are [autofill number] children under the age of 13 living in your household. Are you the parent, guardian, or caregiver of any of these children?

• Yes

• No

[Question H2 will be programmed so that it is only asked if respondent indicated in the household characteristics section that there is anyone over 59 in their household.]

2. Not including financial assistance, do you provide any care or assistance for an adult in your household who needs help because of a condition related to aging?

• Yes

• No

[If the answer to H2 is yes, H3 will be programmed to read: “Do you provide unpaid assistance or care to anyone else in the household…”]

3. Do you provide unpaid assistance or care to anyone in the household because of a health condition or disability? This could include a physical, mental, emotional, cognitive, behavioral or developmental disability; a chronic health condition or psychiatric condition, or blindness or deafness. Assistance can include medical care or help with everyday activities (including supervision or reminders).

• Yes

• No

[The following question is asked only if the respondent indicated above that they are responsible for anyone under age 13 in the household]

4. Are any of the children that live with you cared for in a child care arrangement when they are not in school? Child care includes day care centers or nursery schools, Head Start, before- or after-school care centers, a babysitter, including brothers or sisters, the child’s other parent if that parent does not live with you, or other relatives, and summer camps. Please don’t count kindergarten, first grade, or higher.

• Yes

• No

H5. Currently, do you have any legal agreements or orders that require you to pay child support or alimony?

• Yes

• No

• Don’t know

Section I: Income

1. The next questions are about income or assistance that you or someone in your household may have received in 2017. Remember that, by household, we mean a group of people who live together and purchase food and prepare meals together; or a person who lives alone or who, while living with others, customarily buys food and prepares meals separate and apart from the others. Please indicate if you or anyone in your household received any of the following anytime during 2017, even if for only one month.

   	YES	NO	DON’T KNOW
   a. Wages or salary from regular employment			
   b. Money received from odd jobs, such as child care, babysitting, doing hair, or similar jobs			
   c. WIC or the Special Supplemental Food Program for Women, Infants, and Children			
   d. Food stamps or the Supplemental Nutrition Assistance Program (SNAP)			
   e. Social Security Disability Income (SSDI) or Supplemental Security Income (SSI)			
   f. Public assistance or welfare			
   g. Medicaid			
   h. Housing assistance such as public or low-income subsidized housing or the Housing choice voucher program (Section 8)			
   i. Energy assistance			
   j. Child care subsidy			
   k. Retirement or social security			
   l. Unemployment insurance			
   m. Worker’s compensation			
   n. Child support or alimony			
   o. Other support you received from friends or relatives			
   p. Other (Please specify):			

2. Thinking of all the income received by you and the people in your household during all of 2017, what was the total income for the year for everyone living together in your household? This includes money from jobs, net income from businesses, pensions, dividends, interest, social security payments and any other money income received. Please include all your household’s income before taxes.

Amount

• Don’t know

[If I2=DK, ask I2a. Otherwise, skip to I3]

I2a. Approximately what was your household’s income during 2017?

• Less than $5,000

• $5,001 to $10,000

• $10,001 to $20,000

• $20,001 to $30,000

• $30,001 to $40,000

• $40,001 to $50,000

• $50,001 or more

• Don’t know

3. During the last 12 months, did any of the following happen because your household did not have enough money? Please answer “YES” or “NO” to each item.

   	YES	NO	Don’t Know
   a. The household did not pay the full amount of the rent or mortgage			
   b. The household did not pay the full amount of the gas, oil, or electricity bills			
   c. The gas or electric company turned off service, or the oil company did not deliver oil			
   d. The telephone company disconnected service because payments were not made			
   e. You or someone else in your household needed to see a doctor or go to the hospital but did not go because the household could not afford it			
   f. You or someone else in your household needed to see a dentist but did not go because the household could not afford it			
   G, You or someone else in your household could not fill or postponed filling a prescription for medicine when they were needed because the household could not afford it			

4. Which of these statements best describes the food eaten in your household in the last 12 months?

• We always have enough to eat and the kinds of food I/we want

• We have enough to eat but not always the kinds of food I/we want

• Sometimes I/we don’t have enough to eat

• Often, I/we don’t have enough to eat

5. During the last 12 months, did (you/you or others in your household) ever get emergency food from a church, a food pantry, or food bank?

• Yes

• No ➔ [SKIP TO I7]

• Don’t know➔ [SKIP TO I7]

6. How often did this happen during the last 12 months? Was it…

• Almost every month

• Some months but not every month

• Only 1 or 2 months

7. During the last 12 months, did (you/you or others in your household) ever eat any meals at a soup kitchen?

• Yes

• No ➔ [SKIP TO I9

• Don’t know➔ [SKIP TO I9]

8. How often did this happen during the last 12 months? Was it…

• Almost every month

• Some months but not every month

• Only 1 or 2 months

9. Now we would like to learn about any debts might have other than mortgages and other real estate loans, business debts, and auto loans. Do you have debts from any of these sources?

	YES	NO	Don’t Know
a. Money you owe to family, other relatives, or friends			
b. School loans			
c. Money you owe on one or more credit cards			
d. Other loans (i.e., payday loans or pawn shop loans) (specify type)			

[If at least one source of debt was checked in I9, ask I10. Otherwise, SKIP TO END]

10. Not counting mortgages debt or other real estate loans, business debts, or auto loans, approximately how much do you owe from all these sources?

• $1 to $500

• $501 to $1,000

• $1,001 to $2,500

• $2,501 to $5,000

• $5,001 to $10,000

• $10,001 to $25,000

• $25,001 to $50,000

• More than $50,000

END

Thank you for participating in this important study.

We will be sending your cash incentive and need to make sure we have your correct address.

Street Address 1

Street Address 2 or Apt

City

State

Zip

Telephone

E-Mail

 

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Sara Miller
File Modified	0000-00-00
File Created	2021-01-20