EDECH Individuals & Households

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

B.5.a. HOUSEHOLD SURVEY, BASELINE (ENGLISH)

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Evaluation of Demonstration Projects to End Childhood Hunger

Final Baseline 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 DEMONSTRATION NE CHICKASAW NATION FILL1=two parts - an interview that will take about 30 minutes today, and a second interview about 12 months later. AND FILL3=interview

IF DEMONSTRATION=CHICKASAW NATION FILL1=three parts - an interview that will take about 30 minutes today, a second interview about 12 months from now, and a third interview about 18 months from now. The second and third interviews will also each take about 30 minutes. AND FILL3=interviews

BA1. For quality assurance purposes, this call may be monitored or recorded.

The study has [two parts - an interview that will take about 30 minutes today, and a second interview about 12 months later./three parts - an interview that will take about 30 minutes today, a second interview about 12 months from now, and a third interview about 18 months from now. The second and third interviews will also each take about 30 minutes.] As a way of saying thank you, you will get $30 for completing the interview today and a similar amount for the future [interview/interviews]. We will send you a prepaid gift card after you complete each interview.

The interviews have 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.

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 BB1

DON’T KNOW d

REFUSED r

B. Household Size and Composition

The first few questions are about the people you live with.

ALL

BB1. 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 IF NEEDED: 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

bb1=1

BB1a. 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, CORRECT NUMBER 0 REPEAT BB1

DON’T KNOW d REPEAT BB1

REFUSED r TERMINATE: DK/REF

NUM IN HH

DEMONSTRATION = KENTUCKY OR NAVAJO NATION

BB1b. 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

DEMONSTRATION = NEVADA

BB1c. 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

BB1 GT 1

BB2. Do all the people who live with you share the food that is bought for the household?

YES 1 GO TO BB3

NO 0

DON’T KNOW d

REFUSED r

bb2 ne 1

BB2a. 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 BB2a GT BB1; 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?

BB1 GT 1 OR BB2a GT 1

IF BB2=1 FILL= NUMBER FROM BB1, OTHERWISE FILL=NUMBER FROM BB2a

BB3. How many of those [NUMBER FROM BB1 OR BB2a] people in your household are children age 18 or younger or over 18 but still in high school?

| | | Number of people

(1-20)

NO CHILDREN IN HOUSEHOLD 0 SCREEN OUT:

NO CHILDREN IN HH

DON’T KNOW d

REFUSED r

HARD CHECK: IF BB3 GT BB1; The number of children living in your household is greater than the total number of people in your household. Did I make a mistake?

HARD CHECK: IF BB3 GT BB2a; 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 BB3

IF BB3 GTE 1 AND DEMONSTRATION=KENTUCKY OR NEVADA, GO TO BB3b. ELSE IF BB3=D OR R GO TO BB3a. ELSE GO TO bb4.

BB3=D OR R

BB3a. Is there at least one child living in your household?

YES 1 GO TO BB4

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 16 AND FILL2=December 1, 2015

IF DEMONSTRATION=NEVADA FILL1=is age 5 or younger AND FILL2=July 1, 2015

BB3b. Is there at least one child living in your household who [will be under age 16/was age 5 or under] as of [December 1, 2015/July 1, 2015]?

YES 1

NO 0 SCREEN OUT: NO

ELIG CHILD IN HH

DON’T KNOW d

REFUSED r

BB3 GTE 1

IF BB3 GT 1: first

BB4. 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

BB3 GTE 1

FILL NAME1 FROM BB4

BB4a. What is [NAME1]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

BB4a = D or r

FILL NAME1 FROM BB4

BB4b. 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

BB3 GTE 1

FILL NAME1 FROM BB4

BB4c. 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

BB3 GTE 1 AND AGE GTE 3 YEARS AND DEMONSTRATION = CHICKASAW NATION OR VIRGINIA

FILL NAME1 FROM BB4

BB4d. Is [NAME1] in grades pre-K through 12 in your local school system?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX BB4D

IF BB3 = 1 AND BB4D = 0, SCREEN OUT: NO ELIG CHILD IN HH. ELSE IF BB3=1 AND BB4D = D OR R, Terminate: DK/REF ELIG CHILD in HH. ELSE GO TO BB4E.

BB4d=1 AND DEMONSTRATION=CHICKASAW NATION OR VIRGINIA

FILL NAME1 FROM BB4

BB4e. What school does [NAME1] attend?

[List of schools]

DON’T KNOW d

REFUSED r

BB4d=1 AND DEMONSTRATION = CHICKASAW NATION

FILL NAME1 FROM BB4

BB4f. On school days during the last 30 days, did [NAME1] get free lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

BB4d=1 AND DeMONSTRATION=VIRGINIA

FILL NAME1 FROM BB4

BB4g. On school days during the last 30 days, did [NAME1] get free or reduced price lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

BB3 GT 1

BB5. What is the name of the next 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

BB3 GT 1

FILL NAME2 FROM BB5

BB5a. What is [NAME2]’s date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

Bb5a = D OR R

FILL NAME2 FROM BB5

BB5b. 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

BB3 GT 1

FILL NAME2 FROM BB5

BB5c. 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

BB3 GTE 1 AND AGE GTE 3 YEARS AND DEMONSTRATION = CHICKASAW NATION OR VIRGINIA

FILL NAME2 FROM BB5

BB5d. Is [NAME2] in grades pre-K through 12 in your local school system?

YES 1

NO 0 GO TO PROG

BOX BB5G

DON’T KNOW d GO TO PROG

BOX BB5G

REFUSED r GO TO PROG

BOX BB5G

BB5d = 1 AND DEMONSTRATION = CHICKASAW NATION OR VIRGINIA

FILL NAME2 FROM BB5

BB5e. What school does [NAME2] attend?

[List of schools]

DON’T KNOW d GO TO PROG

BOX BB5G

REFUSED r GO TO PROG

BOX BB5G

BB5d=1 AND DEMONSTRATION=CHICKASAW NATION

FILL NAME2 FROM BB5

BB5f. 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

BB5d=1 AND DeMONSTRATION=VIRGINIA

FILL NAME2 FROM BB5

BB5g. On school days during the last 30 days, did [NAME2] get free or reduced price lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

PROGRAMMER BOX BB5G

LOOP OVER BB5 THROUGH BB5G FOR ALL CHILDREN in BB3.

IF DEMONSTRATION = KENTUCKY AND NO CHILDREN LT AGE 16 YEARS AS OF 12/01/15, TERMINATE. IF DEMONSTRATION = NEVADA and NO CHILDREN LTE AGE 5 YEARS AS OF 07/01/15, TERMINATE. ElSE GO TO BC1.

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

BC1. 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

BC1 NE 0

BC1a. 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

BC1b. 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

BC1b NE 0

BC1c. 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

BC1d. 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

BC1e. 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

BC1f. 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

BC1g. 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

BC2. 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

BC2 GTE 1 AND DEMONSTRATION=VIRGINIA

BC2=1: child

BC2 GT 1: children

BC2a. 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

BC3. How many children in your household received Summer EBT for Children benefits this past summer, that is, summer 2015?

| | | number of children

(0- MAX NUMBER GTE AGE 3 YEARS)

DON’T KNOW d

REFUSED r

BC1a LT NUMBER OF CHILDREn GTE AGE 3 YEARS AND DEMONSTRATION=NAVAJO NATION

BC4. 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 BC5	0	d	r
b. the children attend a school that does not have the school breakfast program?	1 GO TO BC5	0	d	r
c. you do not know about the school breakfast program?	1 GO TO BC5	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

BC1c LT NUMBER OF CHILDREn GTE AGE 3 YEARS AND DEMONSTRATION=NAVAJO NATION

BC5. 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 BC6	0	d	r
b. the children attend a school that does not have the school lunch program?	1 GO TO BC6	0	d	r
c. you do not know about the school lunch program?	1 GO TO BC6	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

BC1F LT NUMBER OF CHILDREn LTE AGE 18 YEARS AND DEMONSTRATION=NAVAJO NATION

BC6. 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 BD1	0	d	r
b. there is no summer food program in area?	1 GO TO BD1	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

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

DEMONSTRATION = CHICKASAW NATION OR KENTUCKY

BD1. 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

BD2. 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

BD3. 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

BD4. 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

BD4a. 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

BD4b. 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

BD5. 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

BD6. 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

BD7. 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

BD8. In the past 12 months, about how many classes, lectures, events, 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:

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

BE1. 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

BE2. “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

BE3. “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 bE3

IF BE1=1 OR 2 OR BE2=1 OR 2 OR BE3=1 OR 2, GO TO BE4; OTHERWISE, SKIP TO BE9.

bE1=1 OR 2 OR bE2=1 OR 2 OR bE3=1 OR 2

IF MULTIPLE ADULTS: or other adults in your household

FILL DATE = DATE OF INTERVIEW -30 DAYS

BE4. 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 BE5

DON’T KNOW d GO TO BE5

REFUSED r GO TO BE5

BE4=1

BE4a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO BE5

(1-30)

DON’T KNOW d

REFUSED r GO TO BE5

BE4A=D

BE4b. 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

bE1=1 OR 2 OR bE2=1 OR 2 OR bE3=1 OR 2

BE5. 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

bE1=1 OR 2 OR bE2=1 OR 2 OR bE3=1 OR 2

BE6. 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

bE1=1 OR 2 OR bE2=1 OR 2 OR bE3=1 OR 2

BE7. 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 BE7

IF BE4=1 OR BE5=1 OR BE6=1 OR BE7=1, GO TO BE8; OTHERWISE, SKIP TO BE9.

BE4=1 OR BE5=1 OR BE6=1 OR BE7=1

IF MULTIPLE ADULTS: or other adults in your household

BE8. 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 BE9

DON’T KNOW d GO TO BE9

REFUSED r GO TO BE9

BE8=1

BE8a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO BE9

(1-30)

DON’T KNOW d

REFUSED r GO TO BE9

BE8a=D

BE8b. 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.

BE9. 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

BE10. 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

BE11. 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 BE11

IF BE9=1 OR 2 OR BE10=1 OR 2 OR BE11=1 OR 2, GO TO BE12; OTHERWISE, SKIP TO BF1.

BE9=1 OR 2 OR BE10=1 OR 2 OR BE11=1 OR 2

IF SINGLE CHILD: your child’s

IF MULTIPLE CHILDREN: any of your children’s

FILL DATE = DATE OF INTERVIEW -30 DAYS

BE12. 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

bE9=1 OR 2 OR bE10=1 OR 2 OR bE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

BE13. 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 BE14

DON’T KNOW d GO TO BE14

REFUSED r GO TO BE14

BE13=1

BE13a. In the last 30 days, how many days did this happen?

| | | NUMBER OF DAYS GO TO BE14

(1-30)

DON’T KNOW d

REFUSED r GO TO BE14

bE13a=D

BE13b. 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

bE9=1 OR 2 OR bE10=1 OR 2 OR bE11=1 OR 2

IF SINGLE CHILD: was your child

IF MULTIPLE CHILDREN: were your children

BE14. 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

bE9=1 OR 2 OR bE10=1 OR 2 OR bE11=1 OR 2

IF SINGLE CHILD: your child

IF MULTIPLE CHILDREN: any of your children

BE15. 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

BF1. 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 BF6

DON’T KNOW d GO TO BF6

REFUSED r GO TO BF6

IF BF1 GT 0

FILL AMOUNT FROM BF1

FILL WEEK/MONTH

BF2. Was any of this $[AMOUNT FROM BF1] 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 BF4

DON’T KNOW d GO TO BF4

REFUSED r GO TO BF4

AMOUNT CANNOT BE MORE THAN THE AMOUNT ENTERED ON QUESTION BF1.

FILL AMOUNT FROM BF1

BF3. About how much of the $[AMOUNT FROM BF1] 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

ALL

BF4. 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 BG1

DON’T KNOW d

REFUSED r

BF4 NE 0

BF5. 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

BG1. 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 BG2

DON’T KNOW d GO TO BG2

REFUSED r GO TO BG2

BG1=1

BG1a. 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 BG2

REFUSED r GO TO BG2

BG1A=1-20 AND ANY CHILDREN LTE AGE 5 YEARS

BG1b. 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

BG2. 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

BG3. 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-diper, or fid-purr?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H. SNAP Enrollment

all

FILL STATE SNAP PROGRAM NAME

BH1. 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 BI1

DON’T KNOW d GO TO BI1

REFUSED r GO TO BI1

bh1=1

FILL STATE SNAP PROGRAM NAME

BH1a. 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

BH2. 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

BH1=1

FILL STATE SNAP PROGRAM NAME

BH3. Are you or others in your household currently receiving [FILL STATE SNAP PROGRAM NAME]?

YES 1

NO 0 GO TO BI1

DON’T KNOW d GO TO BI1

REFUSED r GO TO BI1

BH3=1

FILL STATE SNAP PROGRAM NAME

BH4. 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

bh3=1

BH5. 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

BH3=1

FILL STATE SNAP PROGRAM NAME

BH6. 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. Household Resources

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

BI1. 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 BI1 NE 0

FILL MONTH = CURRENT MONTH -1

BI2. 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 BI3

GAVE ANSWER 1 GO TO BI3

DON’T KNOW d GO TO BI2A

REFUSED r GO TO BI2A

Bi2 GT 12,500

FILL=AMOUNT FROM BI2A

BI2a. You said your household’s total earnings last month was $[AMOUNT FROM BI2], is this correct?

YES 1

NO 0 REPEAT BI2

DON’T KNOW d

REFUSED r

BI2=D OR R

BI2b. 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)

BI3. 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 BI4

GAVE ANSWER 1 GO TO BI4

DON’T KNOW d GO TO BI3B

REFUSED r GO TO BI3B

IF BI3 GT $12,500 ASK

FILL AMOUNT FROM BI3

BI3a. You said your household’s total income last month was [INPUT ANSWER FROM BI3], is this correct?

YES 1

NO 0 REPEAT BI3

DON’T KNOW d

REFUSED r

BI3=D OR R

BI3b. 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

BI4. 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 BI5

GAVE ANSWER 1 GO TO BI5

DON’T KNOW d GO TO BI4A

REFUSED r GO TO BI4A

BI4=D OR R

BI4a. 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 BI5

$10,000 to less than $20,000, 2 GO TO BI5

$20,000 to less than $35,000, 3 GO TO BI5

$35,000 to less than $50,000, 4 GO TO BI5

$50,000 to less than $75,000, 5 GO TO BI5

$75,000 to less than $100,000, 6 GO TO BI5

$100,000 to less than $150,000, or 7 GO TO BI5

$150,000 or more? 8

DON’T KNOW d GO TO BI5

REFUSED r GO TO BI5

IF BI4 GT 150,000 OR BI4A=8

FILL=AMOUNT FROM BI4 or BI4A

BI4b. You said your household’s total income last year was [INPUT ANSWER FROM BI4 OR BI4A], is this correct?

YES 1

NO 0 REPEAT BI4

DON’T KNOW d

REFUSED r

ALL

FILL DATE = DATE OF INTERVIEW -30 DAYS

FILL PROGRAM=STATE WELFARE NAME

BI5. 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

BI5H=1

BI5H_Specify. What is that other income?

(STRING 50)

DESCRIPTION

DON’T KNOW d

REFUSED r

ALL

BI6. 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

BJ1. 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 BJ2

DON’T KNOW d GO TO BJ2

REFUSED r GO TO BJ2

bj1=1

BJ1a. 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) 99

(STRING 50)

DON’T KNOW d

REFUSED r

all

BJ2. 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

BJ3. 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 BK1

DON’T KNOW d GO TO BK1

REFUSED r GO TO BK1

BJ3=1

BJ3a. 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) 99

(STRING 50)

DON’T KNOW d

REFUSED r

K. Respondent Demographics and Health Status

ALL

BK1. 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

BK2. 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

BK3. Are you of Hispanic or Latino origin?

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 0

DON’T KNOW d

REFUSED r

ALL

BK4. 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

BK5. 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

BK6. What is your date of birth?

programmer:

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

MONTH DAY YEAR

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

DON’T KNOW d

REFUSED r

BK6=D OR R

BK6a. 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

MUST BE OLDER THAN 18. IF NOT ASK:

FILL=DATE IN BK6

BK6b. You said your date of birth is [INPUT ANSWER FROM BK6], is this correct?

YES 1

NO 0 REPEAT BK6

DON’T KNOW d

REFUSED r

ALL

BK7. 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

BK8. 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

BL1. Thank you very much for your time. You have really helped us with this study. I’d like to confirm your address so we can send you $30 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]

[IF SECOND FOLLOW-UP FILL EMAIL ADDRESS]

[IF SECOND FOLLOW-UP FILL PHONE NUMBER]

CONTACT INFORMATION IS CORRECT 1 GO TO BL2

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

ALL

BL2. We would also like to do a second telephone interview 12 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 BL2B

REFUSED TO PARTICIPATE IN THIRD INTERVIEW 9 GO TO END

DON’T KNOW d GO TO END

REFUSED r GO TO END

BL2 PHONE NUMBER PROVIDED

BL2a. What type of phone number is this?

HOME 1

CELL 2

WORK 3

OTHER (SPECIFY) 99

(STRING 25)

DON’T KNOW d

REFUSED r

BL2=1, 2, 3, OR PHONE NUMBER PROVIDED

BL2b. 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

BL2=1, 2, 3, OR PHONE NUMBER PROVIDED

BL3. In case we have trouble reaching you in 12 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 relatives or friends 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 BL4

BL3 NE R

BL3a. What is this person’s telephone number, beginning with the area code?

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

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

DON’T KNOW d

REFUSED r G

BL3 NE R

FILL= BL3 FIRST NAME

BL3b. And what is [FIRST NAME]’s relationship to you?

(STRING 25)

RELATIONSHIP

DON’T KNOW d

REFUSED r

BL2=1, 2, 3, OR PHONE NUMBER PROVIDED

BL4. 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

BL3 NE R

BL4a. What is this person’s telephone number, beginning with the area code?

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

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

DON’T KNOW d

REFUSED r

BL3 NE R

FILL= BL4 FIRST NAME

BL4b. And what is [FIRST NAME]’s relationship to you?

(STRING 25)

RELATIONSHIP

DON’T KNOW d

REFUSED r

ALL

IF BL2 NE 9: We look forward to speaking with you again in 12 months.

END. Thank you again for your help and have a good day/evening. [We look forward to speaking with you again in 12 months.]