Team Nutrition Educational Materials for Summer Meals

OMB Control # 0584-0524 | Expiration: 06/30/2016 |Page 1

OMB BURDEN STATEMENT:  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 is 0584-0524. The time to complete this information collection is estimated as part of the 5 minutes for recruitment, including time to review the instructions and completing the information.

Attachment A: Screener for Parents/Caregivers (English Version)

Please choose the option that best answers each question for you.

1. Are you the parent or guardian of any children who live at home with you?

( ) yes

( ) no

2. How many children are there in your home for whom you are the parent or legal guardian? ______________

3. How old are each of these children?

   1. Child #1________

   2. Child #2________

   3. Child #3________

   4. Child #4________

   5. Child #5­________

   6. Child #6________

4. Federal Poverty Level Adjusted for Household Size (see Table 3).

   1. What is the size of your household (Including yourself) ____________

   2. Table 4 Internal Use Only – Income Threshold for Participation
      Household Size	Maximum Annual Household Income
      1	$21,589.00 $29,100.00 $36,611.00 $44,122.00 $51,633.00 $59,144.00 $66,655.00 $74,166.00
      2
      3
      4
      5
      6
      7
      8

      What is your annual household income _____________

5. What is your gender

( ) Male

( ) Female

6. What is your primary language? ________________________

7. Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino

8. Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

9. What is your country of origin? _______________________

10. Does anyone in your household work in any of the following industries?

( ) Nutrition/Food Service

( ) Fitness

( ) Food manufacturing

( ) School Food Service

( ) Food/Nutrition Assistance Programs