EDECH Individuals & Households

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

B.7.a. HOUSEHOLD SURVEY, 18-MONTH FOLLOW-UP (ENGLISH)

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Evaluation of Demonstration Projects to End Childhood Hunger

Final 18-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 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

EA1. 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.

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 EB1

DON’T KNOW d

REFUSED r

B. Household Size and Composition

BASELINE OR FIRST FOLLOW-UP=COMPLETE

FILL HHNUMB FROM BASELINE OR FIRST FOLLOW-UP

EB1. Let’s start by updating our information from our last interview. According to my records, there were [HHNUMB] people in your household that share their food together. Is that still correct?

YES 1 GO TO EB4

NO 0

DON’T KNOW d TERMINATE: DK/REF

NUM IN HH

REFUSED r TERMINATE: DK/REF

NUM IN HH

(BASELINE=NOT COMPLETE AND FIRST FOLLOW-UP=NOT COMPLETE) OR EB1=0

EB2. 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

EB2=1

EB2a. 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 EB2

DON’T KNOW d REPEAT EB2

REFUSED r TERMINATE: DK/REF

NUM IN HH

EB2 GT 1 AND DEMONSTRATION=CHICKASAW NATION

FILL=NAME OF SCHOOL DISTRICT

EB2b. 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

EB2 GT 1

EB3. Do all the people who live with you share the food that is bought for the household?

YES 1 GO TO EB4

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX EB3

IF EB3=1 AND BASELINE=COMPLETE OR FIRST FOLLOW-UP=COMPLETE, GO TO EB4. IF EB3=1 AND BASELINE=NOT COMPLETE AND FIRST FOLLOW-UP=NOT COMPLETE, GO TO EB5. OTHERWISE, GO TO EB3a.

EB3 NE 1

EB3a. 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 EB3A GT EB2; 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 EB3a

if baseline=not complete and First follow-up=Not Complete, go to Eb5. otherwise, go to Eb4.

EB1=1 or (Eb3=1 and BASELINE or first follow-up=complete)

FILL NAME1, DOB1, AND GENDER1 FROM BASELINE OR FIRST FOLLOW-UP

EB4. We would now like to confirm the information we collected in our last interview regarding the children living in your household. I am going to read you the name or initials for each child that we have from our last 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 EB5

NO, INFORMATION IS INCORRECT 2 GO TO EB4A

NO, CHILD NO LONGER LIVES IN HOUSEHOLD 3 GO TO EB5

DON’T KNOW d GO TO EB5

REFUSED r GO TO EB5

EB4=2

FILL NAME1 FROM BASELINE OR FIRST FOLLOW-UP

EB4a. What is [NAME1]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

EB4A=D OR R

FILL NAME1 FROM BASELINE OR FIRST FOLLOW-UP

EB4b. 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

EB4=2

FILL NAME1 FROM BASELINE OR FIRST FOLLOW-UP

EB4c. 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

EB4=2

FILL NAME2, DOB2, AND GENDER2 FROM BASELINE OR FIRST FOLLOW-UP

EB5. Now I’d like to ask about the next child we learned about in our last 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 PROG

BOX EB5C

NO, INFORMATION IS INCORRECT 2 GO TO EB5a

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

BOX EB5C

DON’T KNOW d GO TO PROG

BOX EB5C

REFUSED r GO TO PROG

BOX EB5C

Eb5=2

FILL NAME2 FROM BASELINE OR FIRST FOLLOW-UP

EB5a. What is [NAME2]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

EB5a=D OR R

FILL NAME2 FROM BASELINE OR FIRST FOLLOW-UP

EB5b. 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

EB5=2

FILL NAME2 FROM BASELINE OR FIRST FOLLOW-UP

EB5c. 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 EB5C

LOOP OVER EB5 THROUGH EB5C FOR ALL CHILDREN ON BASELINE OR FIRST FOLLOW-UP HOUSEHOLD ROSTER THEN GO TO EB5D

EB1=1 or (Eb3=1 and BASELINE OR FIRST FOLLOW-UP=complete)

EB5d. 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 GO TO EC1

DON’T KNOW d GO TO EC1

REFUSED r GO TO EC1

Eb5D=1

EB5e. 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 EB5E

go to eb8.

BASELINE=NOT COMPLETE aND first follow-up=not complete

EB6. 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 GO TO EB8

(1-20)

NO CHILDREN IN HOUSEHOLD 0 SCREEN OUT:

NO CHILDREN IN HH

DON’T KNOW d GO TO EB7

REFUSED r GO TO EB7

HARD CHECK: IF EB6 GT EB2; 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 EB6 GT EB3a; 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?

EB6=D or r

EB7. 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

(EB5E NE 0 or d or r) OR (EB6 NE 0 OR D OR R) or Eb7=1

IF EB5E=1 TO 20: For the children we haven’t discussed already,

IF EB5H GT 1 OR EB6 GT 1: first

EB8. [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

(EB5E NE 0 or d or r) OR (EB6 NE 0 OR D OR R) or eb7=1

FILL NAME1 FROM EB8

EB8a. What is [NAME1]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

eB8A=D OR R

FILL NAME1 FROM EB8

EB8b. 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

(EB5E NE 0 or d or r) OR (EB6 NE 0 or d or r) or Eb7=1

FILL NAME1 FROM EB8

EB8c. 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

((EB5E= NE 0 or d or r) OR (EB6 NE 0 or d or r) or Eb7=1) AND AGE GTE 3 YEARS AND DEMONSTRATION=CHICKASAW NATION

FILL NAME1 FROM EB8

EB8d. 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 EB8D

IF EB6=1 AND EB8D=0, SCREEN OUT: NO ELIG CHILD IN HH. ELSE IF EB6=1 AND EB8D=D OR R, Terminate: DK/REF ELIG CHILD in HH. ELSE GO TO EB8E.

EB8D=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME1 FROM EB8

EB8e. What school did [NAME1] attend during the most recently completed school year?

[List of schools]

DON’T KNOW d

REFUSED r

PROGRAMMER BOX EB8E

IF EB6=1 AND EB8E=NOT AN ELIGIBLE SCHOOL, SCREEN OUT: NO ELIG CHILD IN HH. ELSE IF EB6=1 AND EB8E=D OR R, Terminate: DK/REF ELIG CHILD in HH. ELSE GO TO EB8F.

EB8D=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME1 FROM EB8

EB8f. 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

PROGRAMMER BOX EB8F

IF EB6=1 AND EB8F=0, SCREEN OUT: NO ELIG CHILD IN HH. ELSE IF EB6=1 AND EB8F=D OR R, Terminate: DK/REF ELIG CHILD in HH. ELSE GO TO EB9.

EB5E GT1 OR EB6 GT 1

EB9. What is the name of the next child?

(STRING 25)

NAME OR INITIAL

DON’T KNOW d

REFUSED r

EB5E GT1 OR EB6 GT 1

FILL NAME2 FROM EB9

EB9a. What is [NAME2]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

EB9A=D OR R

FILL NAME2 FROM EB9

EB9b. 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

EB5E GT1 OR EB6 GT 1

FILL NAME2 FROM EB9

EB9c. 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

(EB5E OR EB6 GTE 1) AND AGE GTE 3 YEARS AND DEMONSTRATION=CHICKASAW NATION

FILL NAME2 FROM EB9

EB9d. 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 EC1

DON’T KNOW d GO TO EB5

REFUSED r GO TO EB5

EB9d = 1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME2 FROM EB9

EB9e. What school did [NAME2] attend during the most recently completed school year?

[List of schools]

DON’T KNOW d GO TO EB5

REFUSED r GO TO EB5

EB5d=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME2 FROM EB5

EB9f. On school days during the last 30 days, did [NAME2] get free lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX EB9F

LOOP OVER EB9 THROUGH EB9F FOR ALL CHILDREN in EB5E OR EB6 THEN GO TO EC1.

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

EC1. 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

EC1 NE 0

EC1a. 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 ENROLLED IN PRE-K TO 12)

DON’T KNOW d

REFUSED r

AT LEAST ONE CHILD GTE AGE 3 YEARS

EC1b. On school days during the last 30 days, how many children in your household usually ate a lunch provided by the school?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

EC1B NE 0

EC1c. 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

EC1d. 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

EC1e. 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

EC1f. 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

EC1g. 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

EC2. 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

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

ED1. 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

ED2. 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=CHICKASAW NATION OR KENTUCKY

ED3. 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]?

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

EE1. 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

EE2. “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

EE3. “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 EE3

IF EE1=1 OR 2 OR EE2=1 OR 2 OR EE3=1 OR 2, GO TO EE4; OTHERWISE, SKIP TO EE9.

EE1=1 OR 2 OR EE2=1 OR 2 OR EE3=1 OR 2

IF MULTIPLE ADULTS: or other adults in your household

FILL DATE = DATE OF INTERVIEW -30 DAYS

EE4. 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 EE5

DON’T KNOW d GO TO EE5

REFUSED r GO TO EE5

EE4=1

EE4a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO EE5

(1-30)

DON’T KNOW d

REFUSED r GO TO EE5

EE4A=D

EE4b. 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

EE1=1 OR 2 OR EE2=1 OR 2 OR EE3=1 OR 2

EE5. 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

EE1=1 OR 2 OR EE2=1 OR 2 OR EE3=1 OR 2

EE6. 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

EE1=1 OR 2 OR EE2=1 OR 2 OR EE3=1 OR 2

EE7. 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 EE7

IF EE4=1 OR EE5=1 OR EE6=1 OR EE7=1, GO TO EE8; OTHERWISE, SKIP TO EE9.

EE4=1 OR EE5=1 OR EE6=1 OR EE7=1

IF MULTIPLE ADULTS: or other adults in your household

EE8. 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 EE9

DON’T KNOW d GO TO EE9

REFUSED r GO TO EE9

EE8=1

EE8a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO EE9

(1-30)

DON’T KNOW d

REFUSED r GO TO EE9

EE8A=D

EE8b. 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.

EE9. 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.

EE10. 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.

EE11. 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 eE11

IF eE9=1 OR 2 OR eE10=1 OR 2 OR eE11=1 OR 2, GO TO eE12; OTHERWISE, SKIP TO eF1.

eE9=1 OR 2 OR eE10=1 OR 2 OR eE11=1 OR 2

IF SINGLE CHILD: your child’s

IF MULTIPLE CHILDREN: any of your children’s

FILL DATE = DATE OF INTERVIEW -30 DAYS

EE12. 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

EE9=1 OR 2 OR EE10=1 OR 2 OR EE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

EE13. 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 EE14

DON’T KNOW d GO TO EE14

REFUSED r GO TO EE14

EE13=1

EE13a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO EE14

(1-30)

DON’T KNOW d

REFUSED r GO TO EE14

EE13A=D

EE13b. 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

EE9=1 OR 2 OR EE10=1 OR 2 OR EE11=1 OR 2

IF SINGLE CHILD: was your child

IF MULTIPLE CHILDREN: were your children

EE14. 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

EE9=1 OR 2 OR EE10=1 OR 2 OR EE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

EE15. 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

EF1. 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 EF6

DON’T KNOW d GO TO EF6

REFUSED r GO TO EF6

EF1=1 TO 9,999

FILL1=AMOUNT FROM EF1

IF EF1=PER WEEK FILL2=week

IF EF1=PER MONTH FILL2=month

EF2. Was any of this $[AMOUNT FROM EF1] 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 EF4

DON’T KNOW d GO TO EF4

REFUSED r GO TO EF4

EF2=1

FILL=AMOUNT FROM EF1

EF3. About how much of the $[AMOUNT FROM EF1] 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 EF3 PER WEEK GT EF1 PER WEEK OR EF3 PER MONTH GT EF1 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

EF4. 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 EG1

DON’T KNOW d

REFUSED r

EF4 NE 0

EF5. 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

EG1. 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 EG2

DON’T KNOW d GO TO EG2

REFUSED r GO TO EG2

EG1=1

EG1a. 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 EG2

REFUSED r GO TO EG2

EG1A=1-20 AND ANY CHILDREN LTE AGE 5 YEARS

EG1b. 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

EG2. 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

EG3. 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

EG4. 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 EH1

DON’T KNOW d

REFUSED r

EG4 NE 4

EG4a. 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 EH1

Some of the items, or 2

None or nearly none of the items? 3

DON’T KNOW d GO TO EH1

REFUSED r GO TO EH1

EG4A=2 OR 3

EG4b. 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

H. SNAP Enrollment

ALL

FILL STATE SNAP PROGRAM NAME

EH1. In the last 6 months, has your household ever been enrolled in [FILL STATE SNAP PROGRAM NAME], or SNAP?

YES 1

NO 0 GO TO EI1

DON’T KNOW d GO TO EI1

REFUSED r GO TO EI1

EH1=1

FILL STATE SNAP PROGRAM NAME

EH1a. In the last 6 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 1-183) 1

WEEKS (RANGE 1-26) 2

MONTHS (RANGE 1-6) 3

DON’T KNOW d

REFUSED r

ALL

FILL STATE SNAP PROGRAM NAME

EH2. 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

EH1=1

FILL STATE SNAP PROGRAM NAME

EH3. Are you or others in your household currently receiving [FILL STATE SNAP PROGRAM NAME]?

YES 1

NO 0 GO TO EI1

DON’T KNOW d GO TO EI1

REFUSED r GO TO EI1

EH3=1

FILL STATE SNAP PROGRAM NAME

EH4. 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

EH3=1

EH5. In the last 6 months, did the amount of the benefit increase, decrease, or stay the same?

INCREASE 1

DECREASE 2

SAME 3

DON’T KNOW d

REFUSED r

EH3=1

FILL STATE SNAP PROGRAM NAME

EH6. How many weeks do your [FILL STATE SNAP PROGRAM NAME] benefits allotments usually last?

INTERVIEWER: CODE ANY ANSWER GREATER THAN 8 WEEKS AS 8

| | NUMBER OF WEEKS

(0-8)

DON’T KNOW d

REFUSED r

I. Household Resources

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

EI1. 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

ALL

FILL MONTH = CURRENT MONTH -1

EI2. 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 EI3

GAVE ANSWER 1 GO TO EI3

DON’T KNOW d GO TO EI2B

REFUSED r GO TO EI2B

EI2 GT 12,500

FILL=AMOUNT FROM EI2

EI2a. You said your household’s total income last month was $[AMOUNT FROM EI2], is this correct?

YES 1

NO 0 REPEAT EI2

DON’T KNOW d

REFUSED r

EI2=D OR R

EI2b. 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

EI3. 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 EI4

GAVE ANSWER 1 GO TO EI4

DON’T KNOW d GO TO EI3A

REFUSED r GO TO EI3A

EI3=D OR R

EI3a. 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 EI4

$10,000 to less than $20,000, 2 GO TO EI4

$20,000 to less than $35,000, 3 GO TO EI4

$35,000 to less than $50,000, 4 GO TO EI4

$50,000 to less than $75,000, 5 GO TO EI4

$75,000 to less than $100,000, 6 GO TO EI4

$100,000 to less than $150,000, or 7 GO TO EI4

$150,000 or more? 8

DON’T KNOW d GO TO EI4

REFUSED r GO TO EI4

EI3 GT 150,000 OR EI3A=8

FILL=AMOUNT FROM EI3 OR EI3A

EI3b. You said your household’s total income last year was $[AMOUNT FROM EI3 OR EI3A], is this correct?

YES 1

NO 0 REPEAT EI3

DON’T KNOW d

REFUSED r

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL PROGRAM=STATE WELFARE NAME

EI4. 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

EI4H=1

EI4h_Specify. What is that other income?

(STRING 50)

DESCRIPTION

DON’T KNOW d

REFUSED r

ALL

EI5. Now I’d like to ask you about how much help you would expect to get from different sources if your household had a problem with which you needed help, for example, sickness or moving. After I read each source, please tell me if you would you expect to get all of the help needed, most of the help needed, very little of the help needed, or no help?

INTERVIEWER: REPEAT ANSWER CHOICES AS NEEDED.

	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

J. Trigger Events

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

ALL

EJ1. 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 EJ3

DON’T KNOW d GO TO EJ3

REFUSED r GO TO EJ3

EJ1=1

EJ2. 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

EJ3. 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

EJ4. 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 months?

YES 1

NO 0 GO TO EK1

DON’T KNOW d GO TO EK1

REFUSED r GO TO EK1

EJ4=1

EJ4a. 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

K. Respondent Demographics and Health Status

ALL

EK1. 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

EK2. 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

EK3. Are you of Hispanic or Latino origin?

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 0

DON’T KNOW d

REFUSED r

ALL

EK4. 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

EK5. 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

EK6. What is your date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

EK6 = D OR R

EK6a. 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

EK6 LT 18 YEARS

FILL=DATE IN EK6

EK6b. You said your date of birth is [INPUT ANSWER FROM EK6], is this correct?

YES 1

NO 0 REPEAT EK6

DON’T KNOW d

REFUSED r

ALL

EK7. 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

EK8. 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

L. Closing Information

ALL

EL1. Thank you very much for your time. You have really helped us with this study. Now I’d like to confirm your address so we can send you your prepaid $30 card within the next few weeks. 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]

CONTACT INFORMATION IS CORRECT 1

CONTACT INFORMATION NEEDS UPDATING 0

UPDATE: NAME

UPDATE: STREET ADDRESS:

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

ALL

END. Thank you again for your help and have a good day/evening.