EDECH Individuals & Households

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

B.6.a. HOUSEHOLD SURVEY, 12-MONTH FOLLOW-UP (ENGLISH)

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Evaluation of Demonstration Projects to End Childhood Hunger

Final 12-Month Follow-Up Questionnaire for Households

August 13, 2015

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 will be entered after clearance. The time required to complete this information collection is estimated to average 30 to 35 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

A. Introduction

ALL

IF NO FIELD LOCATOR PRESENT FILL1=send

IF FIELD LOCATOR PRESENT FILL1=give

IF DEMONSTRATION=CHICKASAW NATION FILL3= We will also follow up 6 months from now for a final interview that will also take approximately 30 minutes to complete. Will give you another prepaid card at that time for helping us.

TA1. For quality assurance purposes, this call may be monitored or recorded.

The interview will take approximately 30 minutes. It has questions about your children’s food choices as well as general questions about you and your household. Your answers will help the government make its child nutrition programs better. As a way of saying thank you, we will [send/give] you $30 for helping us. [We will also follow up 6 months from now for a final interview that will also take approximately 30 minutes to complete. Will give you another prepaid card at that time for helping us.]

Your participation in this interview is voluntary and you may stop at any time. You may also refuse to answer any question. Your benefits will not be affected by any answers to questions or if you choose not to participate.

All the information you give us will be kept private to the extent allowed by law. There is a small risk of the loss of confidentiality of your data, but procedures are in place to minimize this risk. Your name will not be attached to any of your answers. Your information will be used only in combination with information from other households for research purposes.

Do you have any questions about the interview before I begin?

YES 1 GO TO FAQ

NO 0 GO TO TB1

DON’T KNOW d

REFUSED r

B. Household Size and Composition

BASELINE=COMPLETE

FILL HHNUMB FROM BASELINE

TB1. Let’s start by updating our information from last year. According to my records from our last interview, there were [HHNUMB] people in your household that share their food together. Is that still correct?

YES 1

NO 0

DON’T KNOW d TERMINATE: DK/REF

NUM IN HH

REFUSED r TERMINATE: DK/REF

NUM IN HH

PROGRAMMER BOX TB1

IF TB1=1 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA, GO TO TB4. ELSE IF TB1=0 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA, GO TO TB2. ELSE IF TB1=0 AND DEMONSTRATION=KENTUCKY OR NAVAJO NATION, GO TO TB1A. ELSE GO TO TB1B.

DEMONSTRATION=KENTUCKY OR NAVAJO NATION

TB1a. In which county do you currently live?

[List of eligible counties]

DON’T KNOW r TERMINATE: DK/REF

RESIDENCE

REFUSED r TERMINATE: DK/REF

RESIDENCE

PROGRAMMER BOX TB1A

IF TB1=1, GO TO TB4. ELSE GO TO TB2.

DEMONSTRATION=NEVADA

TB1b. What is your current ZIP Code?

[List of eligible ZIP Codes]

DON’T KNOW r TERMINATE: DK/REF

RESIDENCE

REFUSED r TERMINATE: DK/REF

RESIDENCE

PROGRAMMER BOX TB1B

IF TB1=1, GO TO TB4. ELSE GO TO TB2.

BASELINE=NOT COMPLETE OR TB1=0

TB2. Including yourself, how many people live in your household? Don’t forget to include non-relatives who live in your household and, of course, babies, small children and foster children. Also include people who usually live in your household but may have been away within the last 30 days for reasons such as: vacation, traveling for work, or in the hospital. Do not include children living away at school or anyone who is now incarcerated.

PROBE: By temporarily away we mean away within the last 30 days.

| | | Number of people

(1-20)

DON’T KNOW d TERMINATE: DK/REF

NUM IN HH

REFUSED r TERMINATE: DK/REF

NUM IN HH

TB2=1

TB2a. Just to confirm, you are the only person living in the household. There are no children, non-relatives, or people who usually live there but are currently away?

YES 1 SCREEN OUT:

1 PERSON IN HH

NO 0 REPEAT TB2

DON’T KNOW d REPEAT TB2

REFUSED r SCREEN OUT:

1 PERSON IN HH

TB2 GT 1 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA

FILL=NAME OF SCHOOL DISTRICT

TB2b. Is there a child living in your home who attended an elementary, middle, or high school during the most recently completed school year, that is, school year 2015-2016, in the [NAME OF SCHOOL DISTRICT]?

PROBE IF CHILDREN ARE IN MORE THAN ONE DISTRICT: I just need to confirm that there is at least one child in your household that attended school in this district during the most recently completed school year. All of your children do not need to attend a school in this district.

YES 1

NO 0 SCREEN OUT:

NO ELIG CHILDREN

DON’T KNOW d SCREEN OUT:

DK/REF ELIG

CHILDREN

REFUSED r SCREEN OUT:

DK/REF ELIG

CHILDREN

TB2 GT 1

TB3. Do all the people who live with you share the food that is bought for the household?

YES 1 GO TO TB4

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB3

IF TB3=1 AND BASELINE=COMPLETE, GO TO TB4. IF TB3=1 AND BASELINE=NOT COMPLETE, GO TO TB5. OTHERWISE, GO TO TB3a.

TB3 NE 1

TB3a. Including yourself, how many people in your household share the food that is bought for the household?

| | | Number of people

(1-20)

DON’T KNOW d

REFUSED r

HARD CHECK: IF TB3A GT TB2; The number of people in your household who share food is greater than the total number of people in your household. Did I make a mistake?

PROGRAMMER BOX TB3A

if baseline=not complete, go to tb5. otherwise, go to tb4.

TB1=1 or (tb3=1 and BASELINE=complete)

FILL NAME1, DOB1, AND GENDER1 FROM BASELINE

TB4. We would now like to confirm the information we collected 12 months ago regarding the children living in your household. I am going to read you the name or initials for each child that we have from last year’s interview. I will also read each child’s date of birth and gender. I would like for you to confirm whether the child still lives in your household and if his or her information is correct. I have [NAME1] with a date of birth of [DOB1] and [GENDER1]. Does [NAME1] still live in your household and is (his/her) information correct?

YES 1 GO TO TB4D

NO, INFORMATION IS INCORRECT 2 GO TO TB4A

NO, CHILD NO LONGER LIVES IN HOUSEHOLD 3 GO TO TB4D

DON’T KNOW d GO TO TB4D

REFUSED r GO TO TB4D

TB4=2

FILL NAME1 FROM BASELINE

TB4a. What is [NAME1]’s date of birth?

programmer:

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1996-2016)

DON’T KNOW d

REFUSED r

TB4A=D OR R

FILL NAME1 FROM BASELINE

TB4b. How old is [NAME1]? This information will help me with asking some questions later.

| | | AGE OF CHILD

WEEKS (rANGE 1-52) 1

MONTHS (RANGE 1-12) 2

YEARS (RANGE 1-18) 3

DON’T KNOW d

REFUSED r

TB4=2

FILL NAME1 FROM BASELINE

TB4c. Is [NAME1] a boy or girl?

INTERVIEWER: ASK IF RESPONDENT HAS NOT ALREADY MENTIONED CHILD’S SEX.

boy 1

girl 2

DON’T KNOW d

REFUSED r

TB4=2

FILL NAME2, DOB2, AND GENDER2 FROM BASELINE

TB4d. Now I’d like to ask about the next child we learned about in last year’s interview. I have [NAME2] with a date of birth of [DOB2] and [GENDER2]. Does [NAME2] still live in your household and is (his/her) information correct?

YES 1 GO TO TB4G

PROG BOX

NO, INFORMATION IS INCORRECT 2 GO TO TB4E

NO, CHILD NO LONGER LIVES IN HOUSEHOLD 3 GO TO TB4G

PROG BOX

DON’T KNOW d GO TO TB4G

PROG BOX

REFUSED r GO TO TB4G

PROG BOX

tb4d=2

FILL NAME2 FROM BASELINE

TB4e. What is [NAME2]’s date of birth?

programmer:

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1996-2016)

DON’T KNOW d

REFUSED r

TB4E=D OR R

FILL NAME2 FROM BASELINE

TB4f. How old is [NAME2]? This information will help me with asking some questions later.

| | | AGE OF CHILD

WEEKS (rANGE 1-52) 1

MONTHS (RANGE 1-12) 2

YEARS (RANGE 1-18) 3

DON’T KNOW d

REFUSED r

TB4E=2

FILL NAME2 FROM BASELINE

TB4g. Is [NAME2] a boy or girl?

INTERVIEWER: ASK IF RESPONDENT HAS NOT ALREADY MENTIONED CHILD’S SEX.

boy 1

girl 2

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB4G

LOOP OVER TB4D THROUGH TB4G FOR ALL CHILDREN ON BASELINE HOUSEHOLD ROSTER THEN GO TO TB4H.

TB1=1 or (tb3=1 and BASELINE=complete)

TB4h. Are there any other children, age 18 or younger, or over 18 but still in high school, in your household that I have not asked about yet?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB4H

IF tb4h=1 go to tb4i. else if tb4h=d or r go to tc1.

else if tb4h=0 and demonstration=kentucky, calculate child ages as of 12/01/15. if at least one is lt 16 years, go to tc1; else, screen out.

else if tb4h=0 and demonstration= nevada, calculate child ages as of 07/01/15. if at least one is lte 5 years, go to tc1; else, screen out.

tb4h=1

TB4i. How many additional children age 18 or younger, or over 18 but still in high school, are in your household that I have not asked about yet?

| | | Number of CHILDREN

(1-20)

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB4I

go to tb7

BASELINE=NOT COMPLETE

TB5. How many children are currently living in your household that were age 18 or younger or over 18 but were still in high school during the most recently completed school year?

| | | Number of CHILDREN

(1-20)

NO CHILDREN IN HOUSEHOLD 0 SCREEN OUT:

NO CHILDREN IN HH

DON’T KNOW d

REFUSED r

HARD CHECK: IF TB5 GT TB2; The number of children living in your household is greater than the total number of people living in your household. Did I make a mistake?

HARD CHECK: IF TB5 GT TB3a; The number of children living in your household is greater than the total number of people sharing food in your household. Did I make a mistake?

PROGRAMMER BOX TB5

if tb5 gte 1 and demonstration=kentucky OR NEVADA, go to tb6a. else if tb5=d or r go to tb6. else go to tb7.

TB5=D or r

TB6. Is there at least one child living in your household?

YES 1

NO 0 SCREEN OUT:

NO CHILDREN IN HH

DON’T KNOW d TERMINATE: DK/REF

NUM OF CHILDREN IN HH

REFUSED r TERMINATE: DK/REF

NUM OF CHILDREN IN HH

DEMONSTRATION=KENTUCKY or nevada

IF DEMONSTRATION=KENTUCKY FILL1=will be under age 17 AND FILL2=December 1, 2016

IF DEMONSTRATION=NEVADA FILL1=was age 6 or younger AND FILL2=July 1, 2016

TB6a. Is there at least one child living in your household who [will be under age 17/was age 6 or under] as of [December 1, 2016/July 1, 2016]?

YES 1

NO 0 SCREEN OUT: NO

ELIG CHILD IN HH

DON’T KNOW d

REFUSED r

(TB4I NE 0 or d or r) OR (TB5 NE 0 or d or r) or tb6=1

IF TB4I=1 TO 20: For the children we haven’t discussed already,

IF TB4I GT 1 OR TB5 GT 1: first

TB7. [For the children we haven’t discussed already,] I’d like to make a list of the first names or initials of the children in your household. This will help me with asking some questions later. What is the name of the [first] child?

IF NEEDED: You can give me the child’s initials or some other way to refer to the child.

(STRING 25)

NAME

DON’T KNOW d

REFUSED r

(TB4I NE 0 or d or r) OR (TB5 NE 0 or d or r) or tb6=1

FILL NAME1 FROM TB7

TB7a. What is [NAME1]’s date of birth?

programmer:

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1996-2016)

DON’T KNOW d

REFUSED r

TB7A=D OR R

FILL NAME1 FROM TB7

TB7b. How old is [NAME1]? This information will help me with asking some questions later.

| | | AGE OF CHILD

WEEKS (rANGE 1-52) 1

MONTHS (RANGE 1-12) 2

YEARS (RANGE 1-18) 3

DON’T KNOW d

REFUSED r

(TB4I NE 0 or d or r) OR (TB5 NE 0 or d or r) or tb6=1

FILL NAME1 FROM TB7

TB7c. Is [NAME1] a boy or girl?

INTERVIEWER: ASK IF RESPONDENT HAS NOT ALREADY MENTIONED CHILD’S SEX.

boy 1

girl 2

DON’T KNOW d

REFUSED r

(TB4I NE 0 or d or r) OR (TB5 NE 0 or d or r) or tb6=1 AND AGE GTE 3 YEARS AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA

FILL NAME1 FROM TB7

TB7d. Was [NAME1] in grades pre-K through 12 in your local school system during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB7D

IF TB4I=1 OR TB5=1 AND TB7D=0, SCREEN OUT: NO ELIG CHILD IN HH. ELSE IF TB41=1 OR TB5=1 AND TB7D=D OR R, Terminate: DK/REF ELIG CHILD in HH. ELSE GO TO tb7E.

TB7d=1 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA

FILL NAME1 FROM TB7

TB7e. What school did [NAME1] attend during the most recently completed school year?

[List of schools]

DON’T KNOW d GO TO TB8

REFUSED r GO TO TB8

tb7d=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME1 FROM TB7

TB7f. Did [NAME1] get free lunches at school during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0

DON’T KNOW d

REFUSED r

tb7d=1 AND DeMONSTRATION=VIRGINIA

FILL NAME1 FROM TB7

TB7g. Did [NAME1] get free or reduced price lunches at school during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0

DON’T KNOW d

REFUSED d

TB4I GT1 OR TB5 GT 1

TB8. What is the name of the next child?

(STRING 25)

NAME OR INITIAL

DON’T KNOW d

REFUSED r

TB4I GT1 OR TB5 GT 1

FILL NAME2 FROM TB8

TB8a. What is [NAME2]’s date of birth?

programmer:

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1996-2016)

DON’T KNOW d

REFUSED r

TB8A=D OR R

FILL NAME2 FROM TB8

TB8b. How old is [NAME1]? This information will help me with asking some questions later.

| | | AGE OF CHILD

WEEKS (rANGE 1-52) 1

MONTHS (RANGE 1-12) 2

YEARS (RANGE 1-18) 3

DON’T KNOW d

REFUSED r

TB4I GT1 OR TB5 GT 1

FILL NAME2 FROM TB8

TB8c. Is [NAME2] a boy or girl?

INTERVIEWER: ASK IF RESPONDENT HAS NOT ALREADY MENTIONED CHILD’S SEX.

boy 1

girl 2

DON’T KNOW d

REFUSED r

(TB4I GT1 OR TB5 GT 1) AND AGE GTE 3 YEARS AND DEMONSTRATION = CHICKASAW NATION OR VIRGINIA

FILL NAME2 FROM TB8

TB8d. Was [NAME2] in grades pre-K through 12 in your local school system during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0 GO TO PROG

BOX TB8G

DON’T KNOW d GO TO PROG

BOX TB8G

REFUSED r GO TO PROG

BOX TB8G

tb8d=1 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA

FILL NAME2 FROM TB8

TB8e. What school did [NAME2] attend during the most recently completed school year?

[List of schools]

DON’T KNOW d GO TO PROG

BOX TB8G

REFUSED r GO TO PROG

BOX TB8G

TB8d=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME2 FROM TB8

TB8f. Did [NAME2] get free lunches at school during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0

DON’T KNOW d

REFUSED r

TB8d=1 AND DeMONSTRATION=VIRGINIA

FILL NAME2 FROM TB8

TB8g. Did [NAME2] get free or reduced price lunches at school during the most recently completed school year, that is, school year 2015-2016?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TB8G

LOOP OVER TB8 THROUGH TB8G FOR ALL CHILDREN in TB4I OR TB5.

IF DEMONSTRATION = KENTUCKY AND NO CHILDREN LT AGE 17 YEARS AS OF 12/01/16, TERMINATE. IF DEMONSTRATION = NEVADA and NO CHILDREN LTE AGE 6 YEARS AS OF 07/01/16, TERMINATE. ElSE GO TO tC1.

PROGRAMMER:

CREATE PROGRAMMED VARIABLES FOR NUMBER OF CHILDREN IN HOUSEHOLD, NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD, AND TOTAL HOUSEHOLD SIZE.

C. Children’s Program Participation

For the next series of questions we’ll be asking about meals and snacks the children in your household may have had during the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)].

AT LEAST ONE CHILD GTE AGE 3 YEARS

TC1. On school days during the last 30 days, how many children in your household usually ate breakfast at school?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

TC1 NE 0

TC1a. On school days during the last 30 days, how many children in your household got free or reduced-price breakfasts at school?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

AT LEAST ONE CHILD GTE AGE 3 YEARS

TC1b. On school days during the last 30 days, how many children in your household usually ate a school lunch?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

TC1B NE 0

TC1c. On school days during the last 30 days, how many children in your household got free or reduced-price lunches at school?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

AT LEAST ONE CHILD GTE AGE 3 YEARS

TC1d. During the last 30 days, how many children in your household got free supper meals at an after school program held in their school building?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

AT LEAST ONE CHILD GTE AGE 3 YEARS

TC1e. During the last 30 days, how many children in your household participated in any other after school program where meals or snacks are served?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

DATE OF INTERVIEW IS BETWEEN (DATE) AND (DATE) AND AT LEAst ONE CHILD LTE AGE 18 YEARS

TC1f. During the last 30 days, how many children in your household received free meals or snacks at places such as summer school, a community center, day camp or park?

| | | number of children

(0- MAX NUMBER LTE AGE 18 YEARS)

DON’T KNOW d

REFUSED r

AT LEAst ONE CHILD LTE AGE 5 YEARS

TC1g.During the last 30 days, how many children in your household received meals or snacks at a daycare center, family or group daycare home, or Head Start center?

IF NEEDED: Please include children who received meals or snacks whether the meals or snacks were free, reduced-price, or paid. Please also include meals and snacks that were included in any payment you made to the center or home.

| | | number of children

(0- MAX NUMBER LTE AGE 5 YEARS)

DON’T KNOW d

REFUSED r

AT LEAST ONE CHILD GTE AGE 3 YEARS

TC2. During the last 30 days, how many children in your household got food through a school backpack food program for children?

PROBE IF NEEDED: The Backpack Food Program provides food for children to take home from school over weekends and holidays.

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

TC2 GTE 1 AND DEMONSTRATION=VIRGINIA

TC2=1: child

TC2 GT 1: children

TC2a. During the most recently completed school year, that is, school year 2015-2016, how often did your [child/children] usually take home a food backpack from school? Would you say…

Less often than once per month, 1

Once per month, 2

Two or three times per month, or 3

Every week? 4

DON’T KNOW d

REFUSED r

DEMONSTRATION=CHICKASAW NATION

TC3. How many children in your household received Summer EBT for Children benefits this past summer, that is, summer 2016?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

TC1a LT NUMBER OF CHILDREn GTE AGE 3 YEARS AND DEMONSTRATION=NAVAJO NAtION

TC4. Which of the following are reasons children in your household aren’t participating in the school breakfast program now? Is it because . . .

	YES	NO	DON’T KNOW	REFUSED
a. the children are not enrolled in school?	1 GO TO TC5	0	d	r
b. the children attend a school that does not have the school breakfast program?	1 GO TO TC5	0	d	r
c. you do not know about the school breakfast program?	1 GO TO TC5	0	d	r
d. you can’t fill out the forms?	1	0	d	r
e. you don’t believe anyone is eligible?	1	0	d	r
f. you’d feel embarrassed having to apply for the school breakfast program?	1	0	d	r
g. it’s not worth the trouble?	1	0	d	r
h. you wouldn’t feel comfortable having children in the household participate in the school breakfast program?	1	0	d	r
i. children were embarrassed to get free or reduced-price meals at school?	1	0	d	r
j. children don’t like the food that’s served?	1	0	d	r

TC1C LT NUMBER OF CHILDREn GTE AGE 3 YEARS AND DEMONSTRATION=NAVAJO NATION

TC5. Which of the following are reasons children in your household aren’t participating in the school lunch program now? Is it because . . .

	YES	NO	DON’T KNOW	REFUSED
a. the children are not enrolled in school?	1 GO TO TC6	0	d	r
b. the children attend a school that does not have the school lunch program?	1 GO TO TC6	0	d	r
c. you do not know about the school lunch program?	1 GO TO TC6	0	d	r
d. you do not know how children participate in the school lunch program?	1	0	d	r
e. you can’t fill out the forms?	1	0	d	r
f. you don’t believe anyone is eligible?	1	0	d	r
g. you’d feel embarrassed having to apply for the school lunch program?	1	0	d	r
h. it’s not worth the trouble?	1	0	d	r
i. you wouldn’t feel comfortable having children in the household participate in the school lunch program?	1	0	d	r
j. children were embarrassed to get free or reduced-price meals at school?	1	0	d	r
k. children don’t like the food that’s served?	1	0	d	r

TC1F LT NUMBER OF CHILDREn LTE AGE 18 YEARS AND DEMONSTRATION=NAVAJO NATION

TC6. Which of the following are reasons children in your household didn’t participate in the summer food program this past summer? Is it because. . .

	YES	NO	DON’T KNOW	REFUSED
a. you do not know about the summer food program?	1 GO TO TD1	0	d	r
b. there is no summer food program in area?	1 GO TO TD1	0	d	r
c. you do not know how children participate in the summer food program?	1	0	d	r
d. you don’t believe anyone in the household is eligible?	1	0	d	r
e. it’s not worth the trouble?	1	0	d	r
f. you wouldn’t feel comfortable having children in the household participate in the summer food program?	1	0	d	r
g. you don’t have transportation to get to the program?	1	0	d	r

D. Food Purchase Behavior and Other Food Behavior

These next questions are about where you shop for food for your household.

DEMONSTRATION = CHICKASAW NATION OR KENTUCKY

TD1. During the past 30 days, about how many times did you or someone in your household shop for food?

| | | NUMBER OF times

(0-30)

DON’T KNOW d

REFUSED r

DEMONSTRATION = CHICKASAW NATION OR KENTUCKY

TD2. During the past 30 days, at what kind of store did you buy most of your groceries?

INTERVIEWER: READ ONLY IF NECESSARY

SUPERMARKETS/GROCERY STORES 1

DISCOUNT STORES SUCH AS WAL-MART, TARGET, OR KMART 2

WAREHOUSE CLUBS, SUCH AS PRICE CLUB, COSTCO, PACE, SAM’S CLUB, OR BJ’S 3

CONVENIENCE STORES SUCH AS 7-11, QUICK CHECK, QUICK STOP 4

GAS STATIONS, SUCH AS SHELL, FLYING J, EXXON, MARATHON, OR AMACO5 5

ETHNIC FOOD STORES SUCH AS BODEGAS, ASIAN FOOD MARKETS, OR CARIBBEAN MARKETS 6

FARMERS’ MARKETS 7

DOLLAR STORES 8

SURPLUS/CLOSE-OUT RETAILERS SUCH AS BIG LOTS 9

OTHER (SPECIFY) 99

(STRING 100)

DON’T KNOW d

REFUSED r

DEMONSTRATION = KENTUCKY

TD3. What is the main reason you shop at that store?

LOW PRICES 1

SALES 2

QUALITY OF FOOD 3

VARIETY OF FOODS (GENERAL) 4

VARIETY OF SPECIAL FOODS (SUCH AS GLUTEN FREE) 5

CLOSE TO HOME/CONVENIENT 6

EASY TO GET TO 7

PRODUCE SELECTION 8

MEAT DEPARTMENT 9

LOYALTY/FREQUENT SHOPPER PROGRAM 10

OTHER (SPECIFY) 99

(STRING 100)

DON’T KNOW d

REFUSED r

DEMONSTRATION = KENTUCKY

TD4. How do you usually get to the store where you bought most of your groceries in the past 30 days?

DRIVE OWN CAR 1

DRIVE SOMEONE ELSE’S CAR 2

SOMEONE ELSE DRIVES ME 3

WALK 4

BUS, SUBWAY, oR OTHER PUBLIC TRANSIT 5

TAXI OR OTHER PAID DRIVER 6

RIDE BICYCLE 7

OTHER (SPECIFY) 99

(STRING 100)

DON’T KNOW d

REFUSED r

DEMONSTRATION = KENTUCKY

TD4a. About how many minutes does it take to go one way from home to that store?

INTERVIEWER: ENTER MIDPOINT IF RANGE IS GIVEN

| | | | NUMBER OF MINUTES ONE WAY

(1-120)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF GT 60; I just want to make sure I recorded your answer correctly. Did you say [NUM]?

DEMONSTRATION=CHICKASAW NATION OR KENTUCKY

TD4b. And approximately how many miles away is that store from your home – one way?

INTERVIEWER: ENTER MIDPOINT IF RANGE IS GIVEN; IF LESS THAN ONE MILE ENTER “0”

| | | NUMBER OF MILES ONE WAY

(1-99)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF GT 30; I just want to make sure I recorded your answer correctly. Did you say [NUM]?

ALL

TD5. How many nights a week does your family typically sit down together to have dinner as a family?

EVERY NIGHT 1

5 or 6 NIGHTS 2

3 or 4 nights 3

1 OR 2 NIGHTS 4

NEVER 5

DON’T KNOW d

REFUSED r

DEMONSTRATION = NEVADA OR VIRGINIA

TD6. During the past 7 days, how many times did you or someone else in your family prepare food for dinner or supper at home? Include times spent putting the ingredients together for dinner or supper, but do not include heating up leftovers.

| | NUMBER (0-7)

Never 0

DON’T KNOW d

REFUSED r

DEMONSTRATION = NEVADA OR VIRGINIA

TD7. How often do you shop with a grocery list? Would you say…

Never, 1

Rarely, 2

Sometimes, 3

Most of the time, or 4

Always? 5

DON’T KNOW d

REFUSED r

DEMONSTRATION=NEVADA OR VIRGINIA

TD8. In the past 12 months, about how many classes, lectures, or demonstrations about how to shop for or prepare nutritious food and meals did you or another adult in your household attend?

| | | SESSIONS

(0-24)

DON’T KNOW d

REFUSED r

E. Food Security

PROGRAMMER BOX SECTION E

SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND CHILDREN IN THE HOUSEHOLD. DEFAULT TO MULTIPLE ADULTS AND MULTIPLE CHILDREN IN HOUSEHOLD.

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

TE1. 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 your household in the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)].

The first statement is “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

ALL

TE2. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

ALL

TE3. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TE3

IF TE1=1 OR 2 OR TE2=1 OR 2 OR TE3=1 OR 2, GO TO TE4; OTHERWISE, SKIP TO TE9.

TE1=1 OR 2 OR TE2=1 OR 2 OR TE3=1 OR 2

IF MULTIPLE ADULTS: or other adults in your household

FILL DATE = DATE OF INTERVIEW -30 DAYS

TE4. In the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)], did 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 TE5

DON’T KNOW d GO TO TE5

REFUSED r GO TO TE5

TE4=1

TE4a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO TE5

(1-30)

DON’T KNOW d

REFUSED r GO TO TE5

TE4A=D

TE4b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW d

REFUSED r

TE1=1 OR 2 OR TE2=1 OR 2 OR TE3=1 OR 2

TE5. In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

TE1=1 OR 2 OR TE2=1 OR 2 OR TE3=1 OR 2

TE6. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

TE1=1 OR 2 OR TE2=1 OR 2 OR TE3=1 OR 2

TE7. In the last 30 days, did you lose weight because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TE7

IF TE4=1 OR TE5=1 OR TE6=1 OR TE7=1, GO TO TE8; OTHERWISE, SKIP TO TE9.

TE4=1 OR TE5=1 OR TE6=1 OR TE7=1

IF MULTIPLE ADULTS: or other adults in your household

TE8. In the last 30 days, did you [or 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 TE9

DON’T KNOW d GO TO TE9

REFUSED r GO TO TE9

TE8=1

TE8a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO TE9

(1-30)

DON’T KNOW d

REFUSED r GO TO TE9

TE8a=D

TE8b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW d

REFUSED r

ALL

PROGRAMMER: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND NUMBER OF CHILDREN IN THE HOUSEHOLD.

TE9. Now I’m going to read you several statements that people have made about the food situation of their children. For these statements, please tell me whether the statement was often true, sometimes true, or never true in the last 30 days for [your child/children living in the household who are under 18 years old or 18 or older but still in high school].

IF SINGLE ADULT AND SINGLE CHILD:

“I relied on only a few kinds of low-cost food to feed my child because I was running out of money to buy food.”

IF SINGLE ADULT AND MULTIPLE CHILDREN:

“I relied on only a few kinds of low-cost food to feed my children because I was running out of money to buy food.”

IF MULTIPLE ADULTS AND SINGLE CHILD:

“We relied on only a few kinds of low-cost food to feed our child because we were running out of money to buy food.”

IF MULTIPLE ADULTS AND MULTIPLE CHILDREN:

“We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.”

SHOW FOR ALL:

Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

ALL

PROGRAMMER: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND NUMBER OF CHILDREN IN THE HOUSEHOLD.

TE10. IF SINGLE ADULT AND SINGLE CHILD:

“I couldn’t feed my child a balanced meal, because I couldn’t afford that.”

IF SINGLE ADULT AND MULTIPLE CHILDREN:

“I couldn’t feed my children a balanced meal, because I couldn’t afford that.”

IF MULTIPLE ADULTS AND SINGLE CHILD:

“We couldn’t feed our child a balanced meal, because we couldn’t afford that.”

IF MULTIPLE ADULTS AND MULTIPLE CHILDREN:

“We couldn’t feed our children a balanced meal, because we couldn’t afford that.”

SHOW FOR ALL:

Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

ALL

PROGRAMMER: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND NUMBER OF CHILDREN IN THE HOUSEHOLD.

TE11. IF SINGLE ADULT AND SINGLE CHILD:

“My child was not eating enough because I just couldn’t afford enough food.”

IF SINGLE ADULT AND MULTIPLE CHILDREN:

“My children were not eating enough because I just couldn’t afford enough food.”

IF MULTIPLE ADULTS AND SINGLE CHILD:

“Our child was not eating enough because we just couldn’t afford enough food.”

IF MULTIPLE ADULTS AND MULTIPLE CHILDREN:

“Our children were not eating enough because we just couldn’t afford enough food.”

SHOW FOR ALL:

Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TE11

IF TE9=1 OR 2 OR TE10=1 OR 2 OR TE11=1 OR 2, GO TO TE12; OTHERWISE, SKIP TO TF1.

TE9=1 OR 2 OR TE10=1 OR 2 OR TE11=1 OR 2

IF SINGLE CHILD: your child’s

IF MULTIPLE CHILDREN: any of your children’s

FILL DATE = DATE OF INTERVIEW -30 DAYS

TE12. In the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)], did you ever cut the size of [your child’s/any of your children’s] meals because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

TE9=1 OR 2 OR TE10=1 OR 2 OR TE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

TE13. In the last 30 days, did [your child/any of your children] ever skip meals because there wasn’t enough money for food?

YES 1

NO 2 GO TO TE14

DON’T KNOW d GO TO TE14

REFUSED r GO TO TE14

TE13=1

TE13a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO TE14

(1-30)

DON’T KNOW d

REFUSED r GO TO TE14

TE13A=D

TE13b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW d

REFUSED r

TE9=1 OR 2 OR TE10=1 OR 2 OR TE11=1 OR 2

IF SINGLE CHILD: was your child

IF MULTIPLE CHILDREN: were your children

TE14. In the last 30 days, [was your child/were your children] ever hungry but you just couldn’t afford more food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

TE9=1 OR 2 OR TE10=1 OR 2 OR TE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

TE15. In the last 30 days, did [your child/any of your 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

F. Food Expenditures

Now, I’d like to ask some questions about shopping for food and eating at restaurants. These questions are about out-of-pocket spending on food. Later on I will ask you about purchases made with government benefits like SNAP, WIC, or FDPIR.

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

TF1. First I’ll ask you about money spent on food at supermarkets and other stores. Then we will talk about money spent at fast food restaurants and other restaurants.

Excluding any government benefits like SNAP or WIC, since [DATE (DATE OF INTERVIEW –30 DAYS)] how much money did your family spend out of pocket at supermarkets, grocery stores, and other stores? Please do not include fast food restaurants and other types of restaurants.

PROBE: This includes stores such as Wal-Mart, Target, and Kmart, convenience stores like 7-11 or Mini Mart, stores like Costco or Sam’s Club, dollar stores, bakeries, meat markets, vegetable stands, or farmer’s markets.

PROBE: Please include the total amount spent in the past 30 days, since [DATE (DATE OF INTERVIEW –30 DAYS)].

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

$ | | | | | MONEY SPENT ($1-$9,999)

NO MONEY SPENT 0 GO TO TF6

DON’T KNOW d GO TO TF6

REFUSED r GO TO TF6

TF1=1 TO 9,999

FILL1=AMOUNT FROM TF1

IF TF1=PER WEEK FILL2=week

IF TF1=PER MONTH FILL2=month

TF2. Was any of this $[AMOUNT FROM TF1] per [week/month] spent on nonfood items such as cleaning or paper products, pet food, cigarettes, or alcoholic beverages?

YES 1

NO 0 GO TO TF4

DON’T KNOW d GO TO TF4

REFUSED r GO TO TF4

TF2=1

FILL=AMOUNT FROM TF1

TF3. About how much of the $[AMOUNT FROM TF1] was spent on nonfood items?

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

$ | | | | | MONEY SPENT ($1-$9,999)

NO MONEY SPENT 0

DON’T KNOW d

REFUSED r

HARD CHECK: IF TF3 PER WEEK GT TF1 PER WEEK OR TF3 PER MONTH GT TF1 PER MONTH; The amount spent on nonfood items is greater than the total amount spent at supermarkets or other stores. Did I make a mistake?

ALL

TF4. During the last 30 days, how many times did your family eat food from a fast food restaurant or other kinds of restaurants? Include restaurant meals at home, at fast food or other restaurants, carryout, or drive thru.

PROBE IF NEEDED: Please include the total number of visits in the past 30 days, since [DATE (DATE OF INTERVIEW –30 DAYS)].

PROBE IF NEEDED: Such as food you get at McDonald’s, KFC, Panda Express, Taco Bell, Pizza Hut, food trucks, Applebee’s, Chili’s, TGI Fridays, etc.

| | | times (1-99)

Never 0 GO TO TG1

DON’T KNOW d

REFUSED r

TF4 NE 0

TF5. About how much money did your family spend on food at all types of restaurants including fast food restaurants during the last 30 days?

PROBE: Please include the total amount spent in the past 30 days, since [DATE (DATE OF INTERVIEW –30 DAYS)].

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

$ | | | | | MONEY SPENT ($1-$9,999)

NO MONEY SPENT 0

DON’T KNOW d

REFUSED r

G. Other Program Participation

Next, I’m going to read the names of some programs that provide food or meals or other services to individuals or households.

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

TG1. In the last 30 days, that is, since [DATE OF INTERVIEW -30 DAYS], did you or anyone in your household receive food or benefits from the Women, Infants and Children program called WIC?

YES 1

NO 0 GO TO TG2

DON’T KNOW d GO TO TG2

REFUSED r GO TO TG2

TG1=1

TG1a. How many women, infants, or children in the household got WIC foods or benefits?

| | | Number of women, INFANTS, or children

(1-20)

DON’T KNOW d GO TO TG2

REFUSED r GO TO TG2

TG1A=1-20 AND ANY CHILDREN ARE LTE AGE 5 YEARS

TG1b. Of those, how many were infants or children up to age 5?

| | | Number of INFANTS OR CHILDREN

(0-MAX NUMBER OF CHILDREN LTE AGE 5 YEARS)

DON’T KNOW d

REFUSED r

ALL

TG2. In the last 30 days did you or anyone in your household receive food or meals from food pantries, food banks, local soup kitchens or emergency kitchens, community program, senior center, shelter, Meals on Wheels (or other programs delivering meals to your home), or church?

YES 1

NO 0

DON’T KNOW d

REFUSED r

DEMONSTRATION=CHICKASAW nation OR NAVAJO NATION

TG3. Do you or others in your household currently receive monthly commodity foods as part of the Food Distribution Program on Indian Reservations, also called FDPIR, fi-dipper, or fid-purr?

YES 1

NO 0

DON’T KNOW d

REFUSED r

DEMONSTRATION=CHICKASAW NATION AND IN TREATMENT GROUP

TG4. How often did you try the recipes included with each Direct Mail food delivery?

Every time or nearly every time, 1

Sometimes, or 2

None of the time or nearly none of the time? 3

DID NOT ORDER/RECEIVE A FOOD DELIVERY (VOLUNTEERED) 4 GO TO TH1

DON’T KNOW d

REFUSED r

TG4 NE 4

TG4a. About how much of the Direct Mail food delivery does your household eat each time you receive it? Would you say…

All or most of the items, 1 GO TO TH1

Some of the items, or 2

None or nearly none of the items? 3

DON’T KNOW d GO TO TH1

REFUSED r GO TO TH1

TG4A=2 OR 3

TG4b. What does your household do with the items that aren’t used in the month they are delivered? Does your household…

Save the items for another time, 1

Give the items to family or friends, or 2

Throw the items away? 3

DON’T KNOW d

REFUSED r

dEMONSTRATION=NAVAJO NATION

TG5. Do you recall hearing about the Food Access Navigation, or FAN, Project?

YES 1

NO 0 GO TO TH1

DON’T KNOW d GO TO TH1

REFUSED r GO TO TH1

TG5=1

TG5a. In the past 12 months, how many Food Access Navigation meetings did you attend in your community?

| | | MEETINGS

(0-12)

DON’T KNOW d

REFUSED r

DEMONSTRATION=NEVADA AND IN TREATMENT GrOUP

TG6. In the past 12 months, how many times did you meet with a SNAP-E Plus case manager?

| | | times

(0-24)

DON’T KNOW d

REFUSED r

H. SNAP Enrollment

ALL

FILL STATE SNAP PROGRAM NAME

TH1. In the last 12 months, has your household ever been enrolled in [FILL STATE SNAP PROGRAM NAME], or SNAP?

YES 1

NO 0 GO TO TI1

DON’T KNOW d GO TO TI1

REFUSED r GO TO TI1

TH1=1

FILL STATE SNAP PROGRAM NAME

TH1a. In the last 12 months, how long did your household receive [FILL STATE SNAP PROGRAM NAME]? If your household received [FILL STATE SNAP PROGRAM NAME], stopped receiving it, and then started again, please include all of that time.

| | | | amount of time

DAYS (RANGE 1-365) 1

WEEKS (RANGE 1-52) 2

MONTHS (RANGE 1-12) 3

DON’T KNOW d

REFUSED r

ALL

FILL STATE SNAP PROGRAM NAME

TH2. In total, how long have you and your household ever received [FILL STATE SNAP PROGRAM NAME]?

IF NEEDED: Please include all of the time your household has received [FILL STATE SNAP PROGRAM NAME], even if your household has started and stopped receiving benefits more than once.

| | | | amount of time

NEVER 0

DAYS (RANGE 1-365) 1

WEEKS (RANGE 1-52) 2

MONTHS (RANGE 1-12) 3

YEARS (RANGE 1-50) 4

DON’T KNOW d

REFUSED r

TH1=1

FILL STATE SNAP PROGRAM NAME

TH3. Are you or others in your household currently receiving [FILL STATE SNAP PROGRAM NAME]?

YES 1

NO 0 GO TO TI1

DON’T KNOW d GO TO TI1

REFUSED r GO TO TI1

TH3=1

FILL STATE SNAP PROGRAM NAME

TH4. What is the amount of the [FILL STATE SNAP PROGRAM NAME] your household receives per month?

$ | | | | | dollar amount

($1 - $9999)

DON’T KNOW d

REFUSED r

TH3=1

TH5. In the last 12 months, did the amount of the benefit increase, decrease, or stay the same?

INCREASED 1

DECREASED 2

BOTH INCREASED AND DECREASED 3

STAYED SAME 4

DON’T KNOW d

REFUSED r

TH3=1

FILL STATE SNAP PROGRAM NAME

TH6. How many weeks do your [FILL STATE SNAP PROGRAM NAME] benefits usually last?

INTERVIEWER: CODE ANY ANSWER GREATER THAN 8 WEEKS AS 8

| | NUMBER OF WEEKS

(0-8)

DON’T KNOW d

REFUSED r

I. Children’s Food Consumption

PROGRAMMER BOX SECTION I

IF DEMONSTRATION = KENTUCKY, NAVAJO NATION, NEVADA, OR VIRGINIA GO TO TJ1.

IF MORE THAN ONE CHILD IN HOUSEHOLD, USE RANDOM SELECTION TO CHOOSE FOCAL CHILD AGE GTE 2 YEARS. IF ONLY ONE CHILD IN HOUSEHOLD AGE GTE 2 YEARS, THAT CHILD IS THE FOCAL CHILD.

CHICKASAW NATION

IF NUMBER OF CHILDREN GT 1: For the next set of questions, we are going to focus on [CHILD NAME]. This child has been randomly selected and we cannot change to ask about a different child.

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI1. [For the next set of questions, we are going to focus on [CHILD NAME]. This child has been randomly selected and we cannot change to ask about a different child.] We’ll be asking about meals and snacks [CHILD NAME] may have had during the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)].

First, during the past 30 days, how many days did [NAME1] live in your household?

INTERVIEWER: IF RESPONDENT SAYS EVERYDAY, ENTER 30.

| | | number of days

(1-30)

NONE 0

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI2. The next questions are about the different kinds of foods [CHILD NAME] ate or drank during the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)]. When answering, please include meals and snacks eaten at home, at school or summer school, in restaurants, and anyplace else.

During the last 30 days, how often did [CHILD NAME] eat hot or cold cereal? (You can tell me per day, per week or per month.)

| | | NUMBER of timeS

never 0 GO TO TI3

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI2 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI2

IF TI1=PER DAY FILL2=day

IF TI1=PER WEEK FILL2=week

IF TI1=PER MONTH FILL2=month

TI2.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 2 Repeat TI2

DON’T KNOW d

REFUSED r

TI2 NE 0

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI2.2. During the last 30 days, what kind of cereal did [CHILD NAME] usually eat?

PROBE IF NEEDED: Name and variety and brand

PROBE: What brand of cereal is that?

INTERVIEWER: RECORD INFORMATION FOR ONLY ONE CEREAL. IF MORE THAN ONE CEREAL NAMED, TAKE FIRST CEREAL MENTIONED

(STRING 50)

NAME/VARIETY

KELLOGG’S 1

GENERAL MILLS 2

MALT-O-MEAL 3

POST 4

QUAKER 5

OTHER/STORE BRAND/GENERIC 6

DON’T KNOW d

REFUSED r

PROGRAMMER BOX TI2.2

IF TI2.1 AND TI2.2 =D OR R, GO TO TI3

TI2 NE 0

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI2.3. Was there another cereal that [CHILD NAME] ate?

YES 1

NO 0 GO TO TI3

DON’T KNOW d GO TO TI3

REFUSED r GO TO TI3

TI2.3=1

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL NAME FROM HOUSEHOLD ROSTER

TI2.4. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], what second kind of cereal did [CHILD NAME] usually eat?

PROBE IF NEEDED: Name and variety and brand

PROBE: What brand of cereal is that?

INTERVIEWER: RECORD INFORMATION FOR ONLY ONE CEREAL. IF MORE THAN ONE CEREAL NAMED, TAKE FIRST CEREAL MENTIONED

(STRING 50)

NAME/VARIETY

KELLOGG’S 1

GENERAL MILLS 2

MALT-O-MEAL 3

POST 4

QUAKER 5

OTHER/STORE BRAND/GENERIC 6

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI3. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] have regular soda or pop that contains sugar? Do not include diet soda. (You can tell me per day, per week or per month.)

Include Manzanita (man-zuh-nee-tuh) and Peñafiel (pen-yah-fee-el) sodas. Do not include diet or sugar-free drinks, or juices or tea in cans.

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-12) 1

PER WEEK (RANGE 1-84) 2

PER MONTH (RANGE 1-300) 3

DON’T KNOW d

REFUSED r

TI3 DAY GT 2 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI3

IF TI3=PER DAY FILL2=day

IF TI34=PER WEEK FILL2=week

IF TI3=PER MONTH FILL2=month

TI3.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI3

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI4. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] have 100% pure fruit juice, such as orange, mango, apple, grape, and pineapple juice? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home with added sugar. (You can tell me per day, per week or per month.)

Include only 100% pure juices. Do not include fruit-flavored drinks with added sugar, like cranberry drink, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico (tam-pee-koh), or Sunny Delight.

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-12) 1

PER WEEK (RANGE 1-84) 2

PER MONTH (RANGE 1-300) 3

DON’T KNOW d

REFUSED r

TI4 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI4

IF TI4=PER DAY FILL2=day

IF TI4=PER WEEK FILL2=week

IF TI4=PER MONTH FILL2=month

TI4.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI4

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI5. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] drink coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-12) 1

PER WEEK (RANGE 1-84) 2

PER MONTH (RANGE 1-300) 3

DON’T KNOW d

REFUSED r

TI5 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI5

IF TI5=PER DAY FILL2=day

IF TI5=PER WEEK FILL2=week

IF TI5=PER MONTH FILL2=month

TI5.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI5

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI6. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] drink sweetened fruit drinks, sports or energy drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water? Include fruit juices you made at home with added sugar. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week or per month.)

| | | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-12) 1

PER WEEK (RANGE 1-84) 2

PER MONTH (RANGE 1-300) 3

DON’T KNOW d

REFUSED r

TI6 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI6

IF TI6=PER DAY FILL2=day

IF TI6=PER WEEK FILL2=week

IF TI6=PER MONTH FILL2=month

TI6.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI6

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI7. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat fruit? Include fresh, frozen or canned fruit. Do not include juices or dried fruits. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI7 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI7

IF TI7=PER DAY FILL2=day

IF TI7=PER WEEK FILL2=week

IF TI7=PER MONTH FILL2=month

TI7.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI7

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI8. During the last 30 days, how often did [CHILD NAME] eat a green leafy or lettuce salad, with or without other vegetables? Include spinach salads. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI8 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI8

IF TI8=PER DAY FILL2=day

IF TI8=PER WEEK FILL2=week

IF TI8=PER MONTH FILL2=month

TI8.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI8

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI9. During the last 30 days, how often did [CHILD NAME] eat any kind of fried potatoes, including French fries, home fries, or hash brown potatoes? Do not include potato chips. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI9 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI9

IF TI9=PER DAY FILL2=day

IF TI9=PER WEEK FILL2=week

IF TI9=PER MONTH FILL2=month

TI9.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI9

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI9.2 During the last 30 days, how often did [CHILD NAME] eat other kinds of potatoes such as mashed potatoes, sweet potatoes, or potato salad? Include potatoes au gratin, scalloped potatoes, and all types of potatoes except fried. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI9.2 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI9.2

IF TI9.2=PER DAY FILL2=day

IF TI9.2=PER WEEK FILL2=week

IF TI9.2=PER MONTH FILL2=month

TI9.3 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI9.2

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI10. During the last 30 days, how often did [CHILD NAME] eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans. Include soybeans, kidney, pinto, garbanzo, black beans, lentils, black eyed peas, cow peas, and lima beans. Include canned beans and hummus. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI10 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI10

IF TI10=PER DAY FILL2=day

IF TI10=PER WEEK FILL2=week

IF TI10=PER MONTH FILL2=month

TI10.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI10

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI11. During the last 30 days, how often did [CHILD NAME] eat brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do not include white rice.

PROBE IF NEEDED: Brown rice is a type of whole grain. It is brown in color and takes longer to cook than white rice. It contains almost all of the rice grain and is not as processed as white rice. Compared to white rice it also contains more fiber and more of some vitamins and minerals that are lost during the processing of rice.

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI11 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI11

IF TI11=PER DAY FILL2=day

IF TI11=PER WEEK FILL2=week

IF TI11=PER MONTH FILL2=month

TI11.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI11

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI12. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], not including what you just told me about lettuce salads, potatoes, cooked dried beans, how often did [CHILD NAME] eat other vegetables? Do not include rice. Examples of other vegetables include tomatoes, green beans, carrots, pumpkin, corn, cabbage, bean sprouts, collard greens, and broccoli. Include any form of the vegetable (raw, cooked, canned, or frozen). (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI12 DAY GT 2 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI12

IF TI12=PER DAY FILL2=day

IF TI12=PER WEEK FILL2=week

IF TI12=PER MONTH FILL2=month

TI12.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI12

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI13. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] have Mexican-type salsa made with tomato? Include all tomato-based salsas and Ro-Tel canned tomatoes. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI13 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI13

IF TI13=PER DAY FILL2=day

IF TI13=PER WEEK FILL2=week

IF TI13=PER MONTH FILL2=month

TI13.1 You said (display # of times) per (display unit). Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI13

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI14. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat pizza? Include frozen pizza, fast food pizza, and homemade pizza. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI14 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI14

IF TI14=PER DAY FILL2=day

IF TI14=PER WEEK FILL2=week

IF TI14=PER MONTH FILL2=month

TI14.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI14

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI15. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? Please do not count tomato sauce on pizza. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI15 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI15

IF TI15=PER DAY FILL2=day

IF TI15=PER WEEK FILL2=week

IF TI15=PER MONTH FILL2=month

TI15.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI15

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI16. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat whole grain bread (and tortillas) including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread or potato bread. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI16 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI16

IF TI16=PER DAY FILL2=day

IF TI16=PER WEEK FILL2=week

IF TI16=PER MONTH FILL2=month

TI16.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI16

DON’T KNOW/ d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI17. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat doughnuts, sweet rolls, Danish, muffins, (pan dulce) or Pop-Tarts? Do not include sugar-free items. Include low-fat kinds, Twinkies, and Hostess cupcakes. Do not include pancakes, waffles, French toast, cake, ice cream and other frozen desserts, or candy. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI17 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI17

IF TI17=PER DAY FILL2=day

IF TI17=PER WEEK FILL2=week

IF TI1720=PER MONTH FILL2=month

TI17.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI17

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI18. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat cookies, cake, pie, or brownies? Include low-fat kinds, Twinkies, granola bars, and Hostess cupcakes. Do not include ice cream and other frozen desserts or candy. Do not include sugar-free kinds. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI18 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI18

IF TI18=PER DAY FILL2=day

IF TI18=PER WEEK FILL2=week

IF TI18=PER MONTH FILL2=month

TI18.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI18

DON’T KNOW d

REFUSED r

CHICKASAW NATION

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL CHILD NAME FROM HOUSEHOLD ROSTER

TI19. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], how often did [CHILD NAME] eat popcorn? Include low-fat popcorn. (You can tell me per day, per week or per month.)

| | | | NUMBER of timeS

NEVER 0

PER DAY (RANGE 1-9) 1

PER WEEK (RANGE 1-63) 2

PER MONTH (RANGE 1-270) 3

DON’T KNOW d

REFUSED r

TI19 DAY GT 1 OR WEEK GT 14 OR MONTH GT 60

FILL1=NUMBER FROM TI19

IF TI19=PER DAY FILL2=day

IF TI19=PER WEEK FILL2=week

IF TI19=PER MONTH FILL2=month

TI19.1 You said [display # of times] per [display unit]. Is that correct?

YES, CONTINUE 1

NO, CORRECT NUMBER 0 REPEAT TI19

DON’T KNOW d

REFUSED r

J. Household Resources

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

TJ1. The next questions are about working or jobs. Were you or any other adult in your household working for pay in the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

DEMONSTRATION=KENTUCKY AND TJ1 NE 0

FILL MONTH = CURRENT MONTH -1

TJ2. And what was your household’s total earnings before taxes last month? Please include earnings from wages and salaries from a job or self-employment, or income from a rental property. Do not include income from Social Security, pensions, child support, or cash welfare benefits, or the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

$ | | | | | | DOLLAR AMOUNT ($1 – 99,999)

NO INCOME 0 GO TO TJ3

GAVE ANSWER 1 GO TO TJ3

DON’T KNOW d GO TO TJ2A

REFUSED r GO TO TJ2A

TJ2 GT 12,500

FILL=AMOUNT FROM TJ2

TJ2a. You said your household’s total earnings last month was $[AMOUNT FROM TJ2], is this correct?

YES 1

NO 0 REPEAT TJ2

DON’T KNOW d

REFUSED r

TJ2=D OR R

TJ2b. Some people find it easier to select earnings from a range. Please stop me when I reach your household’s total earnings for last month. Was it…

Less than $500, 1

$500 to less than $1,000, 2

$1,000 to less than $1,500, 3

$1,500 to less than $2,000, 4

$2,000 to less than $2,500, 5

$2,500 to less than $3,000, or 6

$3,000 or more? 7

DON’T KNOW d

REFUSED r

ALL

FILL MONTH = CURRENT MONTH -1

TJ3. What was your household’s total income last month, during [MONTH (CURRENT MONTH -1)] before taxes? Please include all types of income received by all household members last month, including all earnings, Social Security, pensions, Veteran’s Benefits, Unemployment Insurance, worker’s compensation benefits, child support, payments from roomers or boarders, and cash welfare benefits such as TANF (TAH-nif) and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

$ | | | | | | DOLLAR AMOUNT ($1 – 99,999)

NO INCOME 0 GO TO TJ4

GAVE ANSWER 1 GO TO TJ4

DON’T KNOW d GO TO TJ3B

REFUSED r GO TO TJ3B

TJ3 GT 12,500

FILL=AMOUNT FROM TJ3

TJ3a. You said your household’s total income last month was $[AMOUNT FROM TJ2], is this correct?

YES 1

NO 0 REPEAT TJ3

DON’T KNOW d

REFUSED r

TJ3=D OR R

TJ3b. Some people find it easier to select an income range. Please stop me when I reach your household’s total income for last month. Was it…

Less than $500, 1

$500 to less than $1,000, 2

$1,000 to less than $1,500, 3

$1,500 to less than $2,000, 4

$2,000 to less than $2,500, 5

$2,500 to less than $3,000, or 6

$3,000 or more? 7

DON’T KNOW d

REFUSED r

ALL

TJ4. And, what was your household’s total income last year before taxes? Please include all types of income received by all household members last year, including all earnings, Social Security, pensions, Veteran’s Benefits, Unemployment Insurance, worker’s compensation benefits, child support, payments from roomers or boarders, and cash welfare benefits such as TANF (TAH-nif) and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

$ | | | |,| | | | DOLLAR AMOUNT ($1 – 150,000)

NO INCOME 0 GO TO TJ7

GAVE ANSWER 1 GO TO TJ7

DON’T KNOW d GO TO TJ6

REFUSED r GO TO TJ6

TJ4=D OR R

TJ4A. Some people find it easier to select an income range. Please stop me when I reach your household’s total income for last year. Was it…

Less than $10,000, 1 GO TO TJ5

$10,000 to less than $20,000, 2 GO TO TJ5

$20,000 to less than $35,000, 3 GO TO TJ5

$35,000 to less than $50,000, 4 GO TO TJ5

$50,000 to less than $75,000, 5 GO TO TJ5

$75,000 to less than $100,000, 6 GO TO TJ5

$100,000 to less than $150,000, or 7 GO TO TJ5

$150,000 or more? 8

DON’T KNOW d GO TO TJ5

REFUSED r GO TO TJ5

TJ4 GT 150,000 OR TJ4A=8

FILL=AMOUNT FROM TJ4 OR TJ4A

TJ4b. You said your household’s total income last year was $[AMOUNT FROM TJ4 OR TJ4A], is this correct?

YES 1

NO 0 REPEAT TJ4

DON’T KNOW d

REFUSED r

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL PROGRAM=STATE WELFARE NAME

TJ5. The next questions are about sources of income. The answers to these and all other questions on this survey will be kept private and will never be associated with your name. During the last 30 days, that is, since [DATE (DATE OF INTERVIEW -30 DAYS)], did you or anyone in your household receive…

	YES	NO	DON’T KNOW	REFUSED
a. TANF, Temporary Assistance to Needy Families (also known as [STATE WELFARE NAME]) or other welfare such as General Assistance?	1	0	d	r
b. Social Security from the government for retirement, disability, or survivors’ benefits, or other retirement benefits such as a government or private pension or annuity?	1	0	d	r
c. SSI or Supplemental Security Income from the federal, state, or local government?	1	0	d	r
d. Veteran’s Benefits?	1	0	d	r
e. Unemployment Insurance or worker’s compensation benefits?	1	0	d	r
f. Child support payments or payments from roomers or boarders?	1	0	d	r
g. Financial support from friends or family?	1	0	d	r
h. Any other income besides earnings?	1	0	d	r

TJ5H=1

TJ5h_Specify. What is that other income?

(STRING 50)

DESCRIPTION

DON’T KNOW d

REFUSED r

ALL

TJ6. If your household had a problem with which you needed help, for example, sickness or moving, how much help would you expect to get from family living nearby?

	ALL OF THE HELP NEEDED	MOST OF THE HELP NEEDED	VERY LITTLE OF THE HELP NEEDED	NO HELP	DON’T KNOW	REFUSED
a. Family living nearby?	1	2	3	4	d	r
b. Friends?	1	2	3	4	d	r
c. Other people in the community besides family and friends, such as a social service agency or a church?	1	2	3	4	d	r

K. Trigger Events

The next few questions are about changes that may have occurred in your household in the past 6 months.

ALL

TK1. Has there been a change in the number of people living in your household over the past 6 months?

YES 1

NO 0 GO TO TK3

DON’T KNOW d GO TO TK3

REFUSED r GO TO TK3

TK1=1

BASELINE=COMPLETE: I recorded earlier in our interview that there has been a change in the household since the last interview.

TK2. What caused that change?

BIRTH OF CHILD 1

NEW STEP, FOSTER OR ADOPTED CHILD 2

MARRIAGE/NEW PARTNER 3

SEPARATION OR DIVORCE 4

DEATH OF HOUSEHOLD MEMBER 5

FAMILY/BOARDER MOVING IN 6

FAMILY/BOARDER MOVING OUT 7

HOUSEHOLD MEMBER INCARCERATED 8

OTHER (SPECIFY) 9

(STRING 50)

DON’T KNOW d

REFUSED r

all

TK3. At any time in the past 6 months was your household evicted from your house or apartment?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

TK4. Have you or anyone in your household had a change in employment or a change in pay or hours worked from a job in the past 6?

YES 1

NO 0 GO TO TL1

DON’T KNOW d GO TO TL1

REFUSED r GO TO TL1

TK4=1

TK4a. What was that change in employment or a change in pay or hours worked from a job that you or someone in your household experienced in the past 6 months?

CODE ALL THAT APPLY

OBTAINED A JOB 1

LOST JOB 2

INCREASE IN PAY OR HOURS 3

DECREASE IN PAY OR HOURS 4

OTHER (SPECIFY) 9

(STRING 50)

DON’T KNOW d

REFUSED r

L. Respondent Demographics and Health Status

ALL

TL1. Now, I have a few questions about you.

[RECORD GENDER FROM OBSERVATION.]

[ONLY IF NECESSARY – ASK: Because it is sometimes difficult to determine over the phone, I am asked to confirm with everyone…Are you male or female?]

MALE 1

FEMALE 2

DON’T KNOW d

REFUSED r

ALL

TL2. What is your relationship to the children living in the household?

INTERVIEWER: READ ONLY IF NECESSARY

BIOLOGICAL/ADOPTIVE PARENT 1

STEP-PARENT 2

GRANDPARENT 3

GREAT GRANDPARENT 4

SIBLING/STEPSIBLING 5

OTHER RELATIVE OR IN LAW 6

FOSTER PARENT 7

OTHER NON-RELATIVE 8

PARENT’S PARTNER 9

DON’T KNOW d

REFUSED r

ALL

TL3. Are you of Hispanic or Latino origin?

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 0

DON’T KNOW d

REFUSED r

ALL

TL4. I am going to read a list of five race categories. Please choose one or more races that you consider yourself to be. American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander; White?

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

DON’T KNOW d

REFUSED r

ALL

TL5. What is your current marital status? Are you now married, divorced, separated, widowed, never married, or living with a partner?

MARRIED 1

SEPARATED OR DIVORCED 2

WIDOWED 3

NEVER MARRIED 4

LIVING WITH PARTNER 5

DON’T KNOW d

REFUSED r

ALL

TL6. What is your date of birth?

programmer:

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1916-2001)

DON’T KNOW d

REFUSED r

TL6 = D OR R

TL6a. I can record your age instead if you would like. How many years old are you?

| | | YEARS

(18-99)

DON’T KNOW d

REFUSED r

TL6 LT 18 YEARS

FILL=DATE IN TL6

TL6b. You said your date of birth is [INPUT ANSWER FROM TL6], is this correct?

YES 1

NO 0 REPEAT TL6

DON’T KNOW d

REFUSED r

ALL

TL7. What is the highest grade or level of school you have completed or the highest degree you have received?

[ENTER HIGHEST LEVEL OF SCHOOL.]

NEVER ATTENDED/KINDERGARTEN ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA, MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE (EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE: PhD, EdD) 21

DON’T KNOW d

REFUSED r

ALL

TL8. In general, would say your 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

M. Closing Information

DEMONSTRATION=ALL AND IN TREATMENT GrOUP

FILL1=DEMONSTRATION PROJECT NAME

TM1. Thank you very much for your time. You have really helped us with this study. We are also conducting in-person interviews to learn more about some families’ experiences with [DEMONSTRATION PROJECT] and your household’s access to healthy food. Those who are selected for the in-person interview will get $50 in addition to the gift card for this telephone interview. If you agree to take part, one of my colleagues may contact you in the next few weeks with more information and to schedule an interview.

Are you willing to be contacted about taking part in an in-person interview? You can change your mind about participating at a later time.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

IF DEMONSTRATION=CHICKASAW NATION: and other contact information

TM2. Now I’d like to confirm your address [and other contact information] so we can send you your prepaid card within the next few weeks.

[ASK ALL:] According to our records we have…

[FILL NAME FROM SAMPLE FRAME OR SCREENER]

[FILL STREET ADDRESS FROM SAMPLE FRAME]

[FILL CITY, STATE, ZIP CODE FROM SAMPLE FRAME]

[IF SECOND FOLLOW-UP FILL EMAIL ADDRESS]

[IF SECOND FOLLOW-UP FILL PHONE NUMBER]

CONTACT INFORMATION IS CORRECT 1 GO TO TM3

CONTACT INFORMATION NEEDS UPDATING 0

UPDATE: NAME

UPDATE: STREET ADDRESS:

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

| | | | - | | | | - | | | | |

EMAIL

DON’T KNOW d

REFUSED r

DEMONSTRATION=CHICKASAW NATION

TM3. We would also like to do a third telephone survey six months from now to see how you are doing. You will get another prepaid card for participating in that interview.

In case we can’t reach you at this number, is there another number we should try?

| | | | - | | | | - | | | | |

NO ADDITIONAL PHONE AVAILABLE 1

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

REFUSED TO GIVE PHONE NUMBER 3 GO TO TM3b

REFUSED TO PARTICIPATE IN THIRD INTERVIEW 9 GO TO END

DON’T KNOW d GO TO END

REFUSED r GO TO END

TM3 PHONE NUMBER PROVIDED

TM3a. What type of phone number is this?

HOME 1

CELL 2

WORK 3

OTHER (SPECIFY) 99

(STRING 25)

DON’T KNOW d

REFUSED r

TM3=1, 2, 3, OR PHONE NUMBER PROVIDED

TM3b. What is the email address where we can reach you?

(STRING 100)

EMAIL ADDRESS

NO EMAIL ADDRESS AVAILABLE 0

DON’T KNOW d

REFUSED r

TM3=1, 2, 3, OR PHONE NUMBER PROVIDED

TM4. In case we have trouble reaching you in 6 months, please give me the names and telephone numbers of two relatives or friends who would know where you could be reached. These should be friends or relatives not currently living in your household. Let’s start with one friend or relative. What is his or her name?

[BE SURE TO VERIFY SPELLING]

(STRING 25)

FIRST NAME

(STRING 25)

LAST NAME

DON’T KNOW d

REFUSED r GO TO TM5

TM4 NE R

TM4a. What is this person’s telephone number, beginning with the area code?

| | | | - | | | | - | | | | |

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

DON’T KNOW d

REFUSED r

TM4 NE R

FILL= TM4 FIRST NAME

TM4b. And what is [FIRST NAME]’s relationship to you?

(STRING 25)

RELATIONSHIP

DON’T KNOW d

REFUSED r

TM3=1, 2, 3, OR PHONE NUMBER PROVIDED

TM5. How about a second friend or relative? What is his or her name?

[BE SURE TO VERIFY SPELLING]

(STRING 25)

FIRST NAME

(STRING 25)

LAST NAME

DON’T KNOW d

REFUSED r GO TO END

TM5 NE R

TM5a. What is this person’s telephone number, beginning with the area code?

| | | | - | | | | - | | | | |

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

DON’T KNOW d

REFUSED r

TM5 NE R

FILL= TM5 FIRST NAME

TM5b. And what is [FIRST NAME]’s relationship to you?

(STRING 25)

RELATIONSHIP

DON’T KNOW d

REFUSED r

ALL

IF DEMONSTRATION=CHICKASAW NATION AND TL3 NE 9: We look forward to speaking with you again in six months.

END. Thank you again for your help and have a good day/evening. [We look forward to speaking with you again in six months.]