Individual/Households Respondents

ATTACHMENT C.1

registration document

english

OMB Control No.: 0584-xxxx

Expiration Date: 00/00/20xx

SNAP E&T Pilots

Registration Document

September 28, 2015

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 is 0584-xxxx. The time required to complete this information collection is estimated to average 12 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to Food and Nutrition Service, U.S. Department of Agriculture, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.

Contact Info:

1. Participant Name:

First Name:

Middle Initial:

Last Name:

2a. In the past 3 years, have you gone by any other names?

 Yes 1

 No 0 GO TO Q3

2b. Please provide any other names you have been using to identify yourself over the past 3 years (including Maiden name):

First Name1:

Last Name1:

First Name2:

Last Name2:

3. What is your current address?

Street Address 1:

Street Address 2:

City:

State:

Zip:

 No fixed address/No mailing address

4. What is your date of birth?

MONTH DAY YEAR

5. Social Security Number:

6. Gender:

 Male 1

 Female 2

 Other (Specify) 3

___________________________________________

7. Landline Phone Number:

 None

7a. Under whose name is that phone listed?

 My own name 1

 Someone else’s name (SPECIFY) 2

First Name:

Last Name:

8. Cell Phone Number:

 None – GO TO Q9

8a. Do we have your permission to text you to notify you about future surveys for this pilot?

 Yes 1

 No 0

9. Email Address:

 None

DEMOGRAPHIC and well-being information:

10. Are you...

 Hispanic or Latino, 1

 Not Hispanic or Latino 0

11. Please choose one or more races that you consider yourself to be.

Select all that apply

 American Indian or Alaska Native 1

 Asian 2

 Black or African American 3

 Native Hawaiian or Pacific Islander, or 4

 White 5

12. What is your primary spoken language?

Select one only

 English 1 GO TO Q13

 Spanish 2

 Other (SPECIFY) 3

12a. How well would you say you speak English? Would you say…

 Very well 1

 Well 2

 Not well, or 3

 Not at all 4

13. Are you currently…

Select one only

 Married 1

 Living with someone as married, 2

 Separated, 3

 Divorced, 4

 Widowed, or 5

 Never married? 6

14. What is the highest grade or degree you have completed?

Select one only:

 Less than 8th grade 1

 8th to 12th Grade, no diploma 2

 General Equivalency Diploma (GED) 3

 High School Diploma 4

 Adult Basic Education (ABE) certificate 5

 Some college but no degree 6

 Vocational/Technical degree or certificate 7

 Business degree/certificate 8

 Associates degree (AA) 9

 Bachelor’s degree or equivalent (BA/BS) 10

 Master’s degree (MA/MS) or higher (MD, Ph.D) 11

 Other (SPECIFY) 12

14a. In general would you say your health is excellent, very good, good, fair or poor?

 Excellent 1

 Very good 2

 Good 3

 Fair 4

 Poor 5

household composition:

15. Including yourself, how many people live with you? (Please include babies, small children, people who are not related to you, and people who are temporarily away.)

(NUMBER OF PEOPLE LIVING WITH YOU, INCLUDING YOU)

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

 Yes 1 GO TO 18

 No 0

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

(NUMBER OF PEOPLE IN HOUSEHOLD THAT SHARE FOOD WITH YOU, INCLUDING YOU)

18. And (of those), how many people are children age 18 or younger?

(NUMBER OF CHILDREN AGE 18 OR YOUNGER)

employment history:

19. Have you ever worked for pay? Please include self-employment.

 Yes 1

 No 0 GO TO 25a

20. Are you currently self-employed or working at a job for pay?

 Yes 1 GO TO 22

 No 0

21. In what month and year did your last job end?

MONTH YEAR

The next questions are about your current or most recent job. (If you currently have more than one job or had more than one job recently, give answers about your job with the most hours.)

22. What is the name of the company at which you currently or most recently worked?

 Self-employed 1

22a. What (is/was) your job title?

23. What are (or were) your main duties at this company? Please be specific.

24. IF CURRENTLY WORKING, OR DATE LAST JOB ENDED IS LESS THAN 5 YEARS: How many hours per week do (or did) you usually work at your main job?

(HOURS PER WEEK) - GO TO Q25

Varies/Don’t know 1

24a. How many hours did you work during the last week you worked?

(HOURS DURING LAST WEEK WORKED)

Don’t know 1

24b. IF 24a=DK: Would you say you worked….

 Less than 20 hours per week, 1

 Between 20 and 29 hours per week, 2

 Between 30 and 39 hours per week, 3

 Between 40 and 49 hours per week, or 4

 50 or more hours per week? 5

25. IF CURRENTLY WORKING, OR DATE LAST JOB ENDED IS LESS THAN 5 YEARS: What was your current or most recent rate of pay, before taxes and deductions at your main job? IF RATE OF PAY VARIES, PROBE FOR AVERAGE RATE OF PAY

PER

Select one only

 Hour 1

 Week 2

 Every 2 weeks 3

 Twice per month 4

 Once per month 5

 Year 6

 Other (SPECIFY) 7

25a. What is the main reason you (have never worked/are not currently working)?

Select only one.

 Could not find work or lack of jobs available in the area 1

 Lack necessary schooling, training, skills or experience 2

 Could not get along with supervisor or co-workers 3

 Physical or mental health problems 4

 Alcohol or substance abuse 5

 Family responsibilities; caring for children, spouse, or parents 6

 Attending school 7

 Transportation issues or problems (no car or no public transportation available, transportation costs too much) 8

 Chose not to work 9

 Felony record 10

 Other (SPECIFY) 11

other program receipt:

26. Do you, or anyone in your household, currently receive assistance from any of the following programs?

Select all that apply

 SNAP (Food Stamps) [also known as STATE SNAP NAME] 1

 TANF (Temporary Assistance to Needy Families) [also known as STATE TANF NAME] 2

 Medicaid [also known as STATE MEDICAID NAME] 3

 General Assistance 4

 Unemployment Compensation 5

 SSI or SSDI (Supplemental Security Income/Social Security Disability Insurance) 6

 Section 8 or Public Housing Assistance 7

 WIC (Women, Infants, and Children food program) 8

 Other (SPECIFY) 9

 None 0 GO TO 28

IF SNAP NOT SELECTED,

GO TO Q28

27. IF CURRENTLY RECEIVING SNAP: Before you began receiving SNAP benefits this most recent time, had you ever participated in SNAP before?

 Yes 1

 No 0

other contacts:

28. Please provide the name, address, email address, and phone number(s) of two close relatives or friends who do not live with you but who are likely to know how to contact you in the next year. We will only contact these people if we cannot reach you directly.

PERSON 1:

Name:

First Name:

Middle Initial:

Last Name:

Address:

Street Address 1:

Street Address 2:

City:

State:

Zip:

Phone number:

(LANDLINE)

(CELL)

Email address:

What is this person’s relationship to you?

 Parent 1

 Grandparent 2

 Child 3

 Brother/Sister 4

 Friend/Neighbor 5

 Employer 6

 Other (SPECIFY) 7

PERSON 2:

Name:

First Name:

Middle Initial:

Last Name:

Address:

Street Address 1:

Street Address 2:

City:

State:

Zip:

Phone number:

(LANDLINE)

(CELL)

Email address:

What is this person’s relationship to you?

 Parent 1

 Grandparent 2

 Brother/Sister 3

 Friend/Neighbor 4

 Employer 5

 Other (SPECIFY) 6

FOR COUNSELOR USE ONLY:

Likely to be assigned to following track:

   Track A   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

   Track B    (FILL SITE-SPECIFIC INFO)

                 n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

    Track C    (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

    Track D   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 