Individuals/Households

APPENDIX C25. NAMES SURVEY

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

E1. NATIONAL ASSESSMENTOF MEAL ELIGIBILTY AND SERVICES STUDY (NAMES)

HOUSEHOLD SURVEY

SUMMARY:

Interviewers will conduct the household survey with parents/guardians sampled from income eligibility applications.

The interviewer will contact the household by phone for recruitment and to schedule an appointment to conduct the survey. A few days prior to the scheduled date, the interviewer will confirm the date/time for the interview. The interviewer will travel to the respondent’s home (or other designated location) to conduct the survey. At the completion of the interview, the respondent will receive a gift card for $30 or $50. The respondent will receive $30 for completing the interview. If the respondent completes the interview and provides income documentation during the interview, they will receive an additional $20 (for a total of $50).

Interviewers will ensure that respondents are aware that participation in this study is voluntary and will not affect any benefits their child may be receiving. All information is kept private and will never be disclosed in a manner that would identify the parent/guardian or their child.

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 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected.

Notes to Reviewers

Purpose: The following notes to reviewers help to explain the overall flow of the household survey, including how certain sections and/or questions will be repeated where applicable. The notes are organized into overall comments followed by section or question specific notes. Reviewers are encouraged to print these pages and have them to the side while reviewing each section of the household survey.

__________________________________________________________________________________

General Notes:

1. For each question, the “Don’t Know”, “Not Applicable”, and “Refused” response options are not listed on the hardcopy version of the survey. Once the survey is finalized, the Computer Assisted Personal Interview (CAPI) program automatically provides these response options for each question.

2. The CAPI program includes a feature for the interviewer to add a comment to each question using a comment code.

3. Any text that should be read to the respondent by the interviewer is presented as sentences in mixed case text. This includes questions, certain responses, transitions, introductions and optional probes or clarifications.

4. All instructions or notes to the interviewer and/or Programmer are in ALL CAPS. These are not read to the respondent.

1. Programmer notes are numbered within each section (e.g., A1, A2 etc.)

5. For some questions, context specific text will be embedded in the question automatically. This includes information that is computer derived, calculated, or drawn from pre-loaded data about that household. Differential text choices are presented in (parentheses) while names or other specific variables from preloaded data are in [bolded in a bracket] text.

6. Any words that should be emphasized to the respondent by the interviewer are underlined.

Section D

7. This section asks a series of questions to determine if the target child was categorically eligible for free meals. Households that are categorically eligible are not required to complete household size and income questions as part of their application nor this survey.

Section F and G:

8. Responses to these questions will be entered by the interviewer. The interviewer will review these questions with the respondent while reviewing hardcopy documentation along with the respondent. For each section, the interviewer will specify if documentation was available.

Section G:

9. The same question pathway will be triggered for each adult with a reported income source other than paid work. Follow-up questions are triggered if any of the following income sources are received by the household member, as reported in Section F.

• worker’s compensation benefits;

• strike benefits;

• social security or railroad retirement income;

• private pension, annuities, or survivor’s benefits;

• military cash benefits;

• veteran’s benefits;

• government disability benefits from supplemental security income (SSI);

• private disability benefits;

• alimony payments;

• child support payments;

• income from interest and dividends;

• rental income;

• profit or loss from nonfarm business, partnership, or professional practice;

• profit or loss from a farm;

• financial aid to college students;

• money withdrawn from a savings account;

• regular contributions from persons outside the household;

• other income, such as net royalties, trusts, prize winnings, or bonuses;

• receipt of general assistance;

• non-military housing subsidy;

• black lung benefits; and/or

• other kinds of public benefits.

These follow up questions will be asked of the respondent for each additional source of income:

1. What amount was received in the payment during the [application month]?

2. How often was the reported payment made?

3. Was a supporting document about the source of income available to review? And if yes, data collector records the type of document provided.

Also, if available on the documentation, the interviewer will record the start and end date for the income period, and the year-to-date amount.

STUDY ID NUMBER: | | | | | | | | |

DATE: | | | / | | | / | 2 | 0 | 1 | |

MONTH DAY YEAR

INTERVIEWER ID NUMBER: | | | | | |

RESPONDENT’S HOME ADDRESS:

_______________________________________

STREET ADDRESS

_______________________________________

CITY, STATE ZIP

INTERVIEW LOCATION:

RESPONDENT’S HOME 1

OTHER LOCATION, SPECIFY 2

________________________________________________

PROGRAMMING NOTE 1: MOST ITEMS IN THIS SECTION CAN BE AUTOMATICALLY LOADED, EXCEPT THE INTERVIEW LOCATION.

SECTION A: INTRODUCTION AND OBTAINING INFORMED CONSENT

Hello, my name is [interviewer’s full name]. I am here on behalf of the U.S. Department of Agriculture’s (USDA), Food and Nutrition Services (FNS), National Assessment of Meal Eligibility and Services Study, or NAMES Study. IF NEEDED, SAY: You should have received a letter and a brochure that described this study. This study will help the USDA/FNS understand parents’ and children’s experiences with the USDA’s meal program participation at child care centers. I have an appointment with [identified parent/guardian], may I speak with (him/her)?

WHEN IDENTIFIED PARENT OR GUARDIAN IS AVAILABLE: As we discussed during our recent phone call, we are interviewing parents or guardians of children attending [name of sampled child care center]. Your family was randomly selected to be part of this survey. In order to continue, I need approximately 5 minutes to set up my computer. Is it okay if I come inside?

A1. TIME INTERVIEW BEGAN: | | |:| | |

HOUR MINUTE

AM 1

PM 2

PROGRAMMING NOTE A1: AUTOMATICALLY RECORD DATE AND TIME INTERVIEW BEGAN.

A2. CODE IF OBVIOUS, OR ASK: Does [target child name] live with you?

YES 1

NO 2 (GO TO CLOSE SCRIPT # 4)

PROGRAMMING NOTE A2: USE STUDY RECORDS TO PROVIDE INTERVIEWER INSTRUCTIONS OR SPECIAL NOTES FOR INFORMED CONSENT STATUS FOR THIS HOUSEHOLD.

This interview takes about 45 minutes to complete. You will receive $30.00 for completing the survey as our thank you. In addition, you may also receive an additional $20.00 if you provide the requested income documentation. Participation in this study is voluntary and will not affect any benefits you or your child may receive now or in the future. All information is kept private and will never be used in any way that could identify you or your child. REFER TO PRIVACY SECTION OF CONSENT FORM: This section describes the steps the study takes to protect your privacy. Among those steps is the Westat Data Collector Confidentiality Pledge¹ that I signed to keep your information private.

Please review this document that describes this study and what you are being asked to do in detail. HAND RESPONDENT A COPY OF THE CONSENT FORM. Let me know if you have any questions.

WHEN PARENT/GUARDIAN IS FINISHED, ASK: Do you have any questions? TAKE TIME TO ANSWER ALL QUESTIONS APPROPRIATELY. Now, I would like you to sign here (INDICATE SIGNATURE SPACE) to indicate you agree to complete the interview.

A3. DID PARENT/GUARDIAN SIGN THE CONSENT FORM?

YES 1(GO TO A4)

NO 2 (GO TO A5)

A4. Here is a copy of the form you have just signed for your own records. I have also signed your copy to confirm my agreement to keep you information private. Now, unless you have any questions we can get started. GO TO SECTION B.

A5. INTERVIEWER: USE STUDY PROCEDURES TO DOCUMENT WHY CONSENT WAS NOT OBTAINED.

NOT A GOOD TIME, SCHEDULE REVISIT (CLOSE SCRIPT # 1)

REFUSED OR NOT INTERESTED (CLOSE SCRIPT # 2)

NOT SURE ABOUT DOING OR HAS QUESTIONS (CLOSE SCRIPT # 2)

IDENTIFIED PARENT/GUARDIAN NOT AVAILABLE (CLOSE SCRIPT # 3)

IDENTIFIED PARENT/GUARDIAN IS NOT CORRECT (CLOSE SCRIPT # 4)

NO LONGER HAS CUSTODY OF FOSTER CHILD (CLOSE SCRIPT # 4)

TARGET CHILD RESIDES IN GROUP HOME (CLOSE SCRIPT # 4)

TARGET CHILD NOW LIVES WITH ANOTHER

PARENT OR GUARDIAN (CLOSE SCRIPT # 4)

TARGET CHILD DECEASED (CLOSE SCRIPT # 5)

CLOSE SCRIPTS:

1 SCHEDULE NEW APPOINTMENT: Let’s try to find a time that works better for you. What date and time would work for you? INTERVIEWER: CHECK YOUR AVAILABILITY FOR THAT TIME AND DATE, IF AVAILABLE CONFIRM DATE AND TIME AND ADD TO YOUR CALENDAR. IF NOT AVAILABLE, I’m sorry I’m not available at that time but I am available INSERT DATE AND TIME, does that work for you? Thank you for your time today.

2 ADDRESS RESPONDENT CONCERNS: APPLY REFUSAL CONVERSION TECHNIQUES AND FAQS TO ANSWER QUESTIONS OR ADDRESS CONCERNS.

AGREED TO PARTICIPATE AND SIGN FORM (GO TO A3)

REFUSAL (GO TO SCRIPT #6)

3 COLLECT GOOD TIME TO REACH IDENTIFIED PARENT/GUARDIAN: I am sorry that I missed [parent/guardian] today. When would be a good time to contact (him/her) by phone to set a new appointment? RECORD THE CALL BACK INFORMATION. Thank you for your time today.

4 CONTACT INFORMATION FOR BEST ADULT TO ANSWER QUESTIONS: I’m sorry but I must speak with a parent or guardian who lives with [target child]. IF NEEDED: When would be a good time to contact (him/her) by phone to set a new appointment? RECORD THE CONTACT INFORMATION. Thank you for your time today.

5 CONDOLENCE: I am very sorry to hear about your loss. We will not do an interview. RECORD THE CALL BACK INFORMATION. Thank you for your time.

6. REFUSAL: We accept your decision not to participate. Thank you for your time today.

END CONTACT.

SECTION B: CHILD DEMOGRAPHICS & WEEKLY CHILD CARE ROUTINES

INTRO TO SECTION: These next questions ask about the [target child] and (his/her) usual weekly attendance at [name of sampled child care center] and the meals routinely eaten while at [name of sampled child care center].

B1. IF KNOWN, CODE WITHOUT ASKING: Is [target child] male or female?

MALE 1

FEMALE 2

B2. Does [target child] currently attend [name of sampled child care center]?

YES 1 (GO TO B7)

NO 2 (GO TO B3)

B3. When did (she/he) stop attending [name of sampled child care center]?

PROBE: Was it the beginning, middle, or end of the month? BASED ON RESPONSE TO PROBE, RECORD THESE DATES: IF BEGINNING ENTER 05, IF MIDDLE ENTER 15, AND IF END ENTER 25.

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

MONTH DAY YEAR

B4. Is [target child] currently enrolled in another child care center?

YES 1 (GO TO B5)

NO 2 (GO TO SECTION D)

B5. What child care center does [target child] attend now?

__________________________________________________

NAME OF NEW CHILD CARE CENTER

__________________________________________________

STREET ADDRESS

__________________________________________________

CITY, STATE ZIP

B6. What date did (she/he) begin attending [name of new child care center]?

PROBE: Was it the beginning, middle, or end of the month? BASED ON RESPONSE TO PROBE, RECORD THESE DATES: IF BEGINNING ENTER 05, IF MIDDLE ENTER 15, AND IF END ENTER 25.

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

MONTH DAY YEAR

PROGRAMMING NOTE B1 IF TARGET CHILD IS NO LONGER ATTENDING THE SAMPLED CHILD CARE CENTER (B2 = 2, NO), GO TO SECTION D, ELSE CONTINUE.

B7. On what days of the week does your child usually attend [name of child care center]? MARK ALL THAT APPLY.

MONDAY 1

TUESDAY 2

WEDNESDAY 3

THURSDAY 4

FRIDAY 5

B8. On the days [target child] attends [name of sampled child care center], would you describe the time (he/she) spends there as half day or all day?

HALF DAY 1

ALL DAY 2

B9. CODE WITHOUT ASKING IF KNOWN: When was the most recent week, ending on Friday or Saturday, that the [target child] received care at [name of sampled child care center]?

IF NEEDED, ADD: According to the usual routine you just told me about.

LAST WEEK 1

FROM | | | | | | TO | | | | | |

DAY MONTH DAY MONTH

INTRO TO SUBSECTION: Now, think about a typical week that [target child] attended [name of sampled child care center]. The next questions are about the meals [target child] ate at [name of sampled child care center] during a typical week there.

When we speak about the breakfast or lunch provided by [name of sampled child care center], we mean the entire breakfast or lunch that is provided to your child for a meal at one time (in one sitting). We are not talking about individual foods items or beverages that are part of that breakfast or lunch meal.

B10. On a typical week, how many days did [target child] eat breakfast provided by [name of sampled child care center]?

ONE 1

TWO 2

THREE 3

FOUR 4

FIVE 5

B11. On a typical week, how many days did [target child] eat lunch provided by [name of sampled child care center]?

ONE 1

TWO 2

THREE 3

FOUR 4

FIVE 5

PROGRAMMING NOTE B2: IF NUMBER OF DAYS TARGET CHILD TYPICALLY HAS BREAKFAST AT THE CHILD CARE CENTER (B10) ARE FEWER THAN NUMBER OF DAYS OF THE WEEK TARGET CHILD USUALLY ATTENDS THE CHILD CARE CENTER (B7), THEN CONTINUE TO B12. ELSE, (THEY ARE THE SAME) GO TO THE PROGRAMMING NOTE B3.

B12. You just mentioned that [target child] typically does not eat the child care center breakfast on some or all days (she/he) attends the center. Why doesn’t (she/he) typically eat the center breakfast(s)? MARK ALL THAT APPLY

AFTER RESPONSE, SAY: Were there other reasons why (she/he) typically does not eat the center breakfast(s)?

CHILD HAS FOOD ALLERGIES AND/OR SPECIFIC FOOD

NEEDS 1

EATS BREAKFAST AT HOME 2

BRINGS BREAKFAST FROM HOME 3

DOES NOT LIKE THE FOOD AT CENTER 4

NOT ENOUGH TIME TO EAT AT CENTER 5

CHILD DOES NOT EAT BREAKFAST 6

ON A DIET 7

CHILD THINKS ONLY NEEDY CHILDREN EAT

BREAKFASTS AT CHILD CARE CENTER 8

BECAUSE FRIENDS DO NOT EAT IT 9

ARRIVES TOO LATE FOR BREAKSFAST EVERY DAY 10

CHILD OR PARENT/GUARDIAN TOO EMBARRASSED 11

OTHER, SPECIFY __________ 12

PROGRAMMING NOTE B3: IF NUMBER OF DAYS TARGET CHILD TYPICALLY HAS LUNCH AT THE CHILD CARE CENTER (B11) ARE FEWER THAN NUMBER OF DAYS OF THE WEEK TARGET CHILD USUALLY ATTENDS THE CHILD CARE CENTER (B7), THEN ASK B13. ELSE, (THEY ARE THE SAME) GO TO SECTION C.

B13. You just mentioned that [target child] typically does not eat the child care center lunch on some or all days (she/he) receives care at the center. Why doesn’t (she/he) typically eat the center lunch (es)? MARK ALL THAT APPLY

AFTER RESPONSE, SAY: Were there other reasons why (she/he) typically does not eat the center lunch (es)?

CHILD HAS FOOD ALLERGIES AND/OR SPECIFIC FOOD

NEEDS 1

EATS LUNCH AT HOME 2

BRINGS LUNCH FROM HOME 3

DOES NOT LIKE THE FOOD AT CENTER 4

NOT ENOUGH TIME TO EAT AT CENTER 5

CHILD DOES NOT EAT LUNCH 6

ON A DIET 7

CHILD THINKS ONLY NEEDY CHILDREN EAT

LUNCHES AT CHILD CARE CENTER 8

BECAUSE FRIENDS DO NOT EAT IT 9

ARRIVES TOO LATE FOR LUNCH EVERY DAY 10

CHILD OR PARENT/GUARDIAN TOO EMBARRASSED 11

OTHER, SPECIFY __________ 12

SECTION C: PERCEPTIONS OF CHILD CARE CENTER MEALS

INTRO TO SECTION: The next questions are about your child’s satisfaction with meals at [name of sampled child care center]. For this series of questions, please think about if [target child] is very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with certain characteristics of the meals served at [name of sampled child care center].

Please answer only about your child’s satisfaction. We will ask about your satisfaction with the meals later.

PROGRAMMING NOTE C1 QUESTIONS C1 THROUGH C3 ARE ASKED FOR A TARGET CHILD AGED 2 YEARS OR OLDER. IF CHILD IS LESS THAN 2 YEARS OLD, GO TO C4.

C1. Overall, how satisfied is [target child] with the variety and types of foods (she/he) gets at [name of sampled child care center]?

Please answer only about [target child]’s satisfaction. We will ask about your satisfaction with the foods a little later.

VERY SATISFIED 1

SOMEWHAT SATISFIED 2

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

CHILD IS TOO YOUNG TO ACCURATELY REPORT ON SATISFACTION…………………………………………………5

TARGET CHILD NEVER EATS CENTER PROVIDED

MEALS 6 (GO TO SECTION D)

C2. How satisfied is [target child] with how the food tastes?

Please answer only about [target child]’s satisfaction. We will ask about your satisfaction with the foods a little later

VERY SATISFIED 1

SOMEWHAT SATISFIED 2

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

CHILD IS TOO YOUNG TO ACCURATELY REPORT ON SATISFACTION…………………………………………………5

C3. How satisfied is [target child] with the amount or size of the portions of food (she/he) is given in the child care center meals?

VERY SATISFIED 1

SOMEWHAT SATISFIED 2

SOMEWHAT DISSATISFIED 3

VERY DISSATISFIED 4

CHILD IS TOO YOUNG TO ACCURATELY REPORT ON SATISFACTION…………………………………………………5

INTRO TO SUBSECTION: The next question is about your satisfaction with center meals. Again, please tell me overall if are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied.

	Regarding the food program that [target child] receives at [name of sampled child care center], how satisfied are you with…	RESPONSE
C4	…the nutritional quality of the food served?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C5	…the variety and types of food served?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C6	…how the staff prepare the meals?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C7	…the way the meals are served to children (such as family style or cafeteria style)?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C8	….way in which the child care center shares or distributes the menus for the week or month?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C9	…the time of day that meals are served?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C10	…the amount of time children have to eat meals?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4
C11	…the food program overall?	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4

SECTION D: HOUSEHOLD BENEFITS

INTRO TO SECTION: Next, I would like to ask questions about [target child], and benefits your household may receive.

D1. What is [target child]’s relationship to you?

NATURAL CHILD 1

STEPCHILD OR ADOPTED CHILD 2

OTHER CUSTODIAL CHILD 3

FOSTER CHILD 4

AUNT OR UNCLE 5

SIBLING (BROTHER OR SISTER) 6

NEPHEW OR NIECE 7

COUSIN 8

GRANDCHILD 9

OTHER RELATIVE 10

NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 11

OTHER (SPECIFY) 12

D2. What is [target child]’s gender?

FEMALE 1

MALE 2

D3. What is [target child]’s date of birth?

|___|___|/|___|___|/|___|___|

MONTH DAY YEAR

DOES NOT KNOW 1

REFUSED 2

D4. Did [target child] live with you in [application month and year]?

YES 1

NO 2

PROGRAMMING NOTE D1: AFTER CYCLING THROUGH QUESTIONS D1 THROUGH D4, APPLY THE FOLLOWING DELAYED SKIP PATTERN, IF TARGET CHILD IS A FOSTER CHILD (D1 = 4) GO TO SECTION I. THIS MEANS THE TARGET CHILD IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

HOUSEHOLD BENEFITS

The next questions are about benefits received through government programs. It will be helpful to review any documentation you have about payments from these programs so that we can work together to answer the questions.

INTERVIEWER: WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.

TANF BENEFITS

D5. During [application month and year], did you, your spouse, and/or child/children) receive Temporary Assistance for Needy Families (TANF), also known as cash welfare, or [INSERT STATE NAME FOR TANF]?

IF NEEDED: Do not include TANF benefits received by another household member with their own TANF case number that does not include you, your spouse, and/or your child/children.

YES 1

NO 2 (GO TO D17)

D6. We need to record the total amount (you and your (child/children)/you and your spouse and (child/children)) received in (State TANF/TANF) benefits during [application month and year]. We can get that amount from your TANF award statement or notification of payment. Do you have a statement or notification from [application month and year]?

YES 1

NO 2

D7. IF DOCUMENTATION IS PROVIDED RECORD AMOUNT BELOW.

IF NO DOCUMENTATION PROVIDED ASK: How much did you receive in these benefits? IF UNSURE: Your best estimate is fine.

$ |___|___|,|___|___|___|

D8. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

PROGRAMMER NOTE D2: RECORD D9-D14 IF DOCUMENTATION IS PROVIDED (D6=1). IF NO DOCUMENTATION PROVIDED (D6=2) GO TO D15.

D9. INTERVIEWER: RECORD TYPE OF DOCUMENT.

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

D10. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

D11. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|___|,|___|___|___|

AMOUNT NOT FOUND ON
DOCUMENT 99

D12. INTERVIEWER: RECORD THE CASE ID ON THE BENEFITS STATEMENT.

|___|___|___|___|___|___|___|___|___|___|___|___|

CASE ID NOT FOUND ON
DOCUMENT 99

D13. INTERVIEWER: DOES THE TANF BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

PROGRAMMER NOTE D3: ASK D14 IF DOCUMENTATION WAS NOT FOR THE APPLICATION MONTH (D13 ≠ 1)

D14. Is the amount we just discussed as the TANF payment about the same as, less than, or more than the payment received in [application month and year]?

ABOUT THE SAME 1

LESS 2

MORE 3

PROGRAMMER NOTE D4: ASK D15 AND D16 IF NO DOCUMENTATION PROVIDED

(D6 = 2)

D15. Do you have your TANF EBT card, also known as STATE NAME FOR TANF card, that

you can show me?

YES 1

NO 2

D16. INTERVIEWER: DID THE RESPONDENT SHOW A VALID TANF CARD?

YES 1

NO 2

PROGRAMMING NOTE D5: AFTER CYCLING THROUGH QUESTIONS D5 THROUGH D16, APPLY THE FOLLOWING DELAYED SKIP PATTERN: IF HOUSEHOLD RECEIVES TANF BENEFITS (D5 = 1) GO TO SECTION I. THIS MEANS THE TARGET CHILD IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

SNAP BENEFITS

Now let’s discuss any SNAP benefits your household may receive.

D17. During [application month and year], did you, your spouse, and/or child/children receive Supplemental Nutrition Assistance Program (SNAP) benefits (formerly known as Food Stamps), or [INSERT STATE NAME FOR SNAP]?

IF NEEDED: Do not include SNAP benefits received by another household member with their own SNAP case number that does not include you, your spouse, and/or your child/children.

YES 1

NO 2 (GO TO D29)

D18. We need to record the total amount (you and your (child/children)/you and your spouse and (child/children)) received in (State SNAP/SNAP) benefits during [application month and year]. We can get that amount from your SNAP award statement or notification of payment. Do you have a statement or notification from [application month and year]?

YES 1

NO 2

D19. IF DOCUMENTATION IS PROVIDED, RECORD AMOUNT BELOW.

IF NO DOCUMENTATION PROVIDED ASK: How much did you receive in these benefits? IF UNSURE: Your best estimate is fine.

$ |___|___|,|___|___|___|

D20. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

D21. INTERVIEWER: COMPLETE D22 TO D27 IF DOCUMENTATION IS PROVIDED (D18=1). IF NO DOCUMENTATION (D18=2) IS PROVIDED GO TO D27.

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

D22. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

D23. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|___|,|___|___|___|

AMOUNT NOT FOUND ON
DOCUMENT 99

D24. INTERVIEWER: RECORD THE CASE ID ON THE BENEFITS STATEMENT.

|___|___|___|___|___|___|___|___|___|___|___|___|

CASE ID NOT FOUND ON
DOCUMENT 99

D25. INTERVIEWER: DOES THE SNAP BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

PROGRAMMER NOTE D6: ASK D26 IF DOCUMENTATION WAS NOT FOR THE APPLICATION MONTH (D25 ≠ 1)

D26. Is the amount we just discussed as the SNAP payment about the same as, less than, or more than the payment received in [application month and year]?

ABOUT THE SAME 1

LESS 2

MORE 3

PROGRAMMER NOTE D7: ASK D27 AND D28 IF NO DOCUMENTATION PROVIDED (D18 = 2)

D27. Do you have your SNAP EBT card, also known as STATE NAME FOR SNAP card, that

you can show me?

YES 1

NO 2

D28. INTERVIEWER: DID THE RESPONDENT SHOW A VALID SNAP CARD?

YES 1

NO 2

PROGRAMMING NOTE D8: AFTER CYCLING THROUGH QUESTIONS D17 THROUGH D28, APPLY THE FOLLOWING DELAYED SKIP PATTERN: IF HOUSEHOLD RECEIVES SNAP BENEFITS (D17 = 1) GO TO SECTION I. THIS MEANS THE TARGET CHILD IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

OTHER BENEFITS

D29. Did you, your spouse, and/or child/children receive Medicaid benefits during [application month and year]?

YES 1

NO ...2 (GO TO D33)

D30. We need to document that you, your spouse, and/or child/children receive Medicaid benefits. Do you have a Medicaid card or other documentation that shows you receive Medicaid benefits?

YES 1

NO 2 (GO TO D33)

D31. INTERVIEWER: RECORD TYPE OF DOCUMENT.

MEDICAID CARD 1

OTHER DOCUMENTATION 2

D32. INTERVIEWER: RECORD THE CASE ID ON THE MEDICAID CARD.

|___|___|___|___|___|___|___|___|___|___|___|___|

PROGRAMMING NOTE D9: AFTER CYCLING THROUGH QUESTIONS D29 THROUGH D32, APPLY THE FOLLOWING DELAYED SKIP PATTERN: IF HOUSEHOLD RECEIVES MEDICAID BENEFITS (D29 = 1) GO TO SECTION I. THIS MEANS THE TARGET CHILD IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

D33. During [application month and year], did you, your spouse, and/or child/children) participate in the Food Distribution Program for Indian Reservations (FDPIR)?

IF NEEDED: Do not include FDPIR benefits received by another household member with their own case number that does not include you, your spouse, and/or your child/children.

YES 1

NO 2 (GO TO SECTION E)

D34. We need to record the total amount you, your spouse and your (child/children) received in FDPIR benefits during [application month and year]. We can get that amount from your FDPIR award statement or notification of payment. Do you have a statement or notification from [application month and year]?

YES 1

NO 2 (GO TO D42)

D35. IF DOCUMENTATION IS PROVIDED RECORD AMOUNT BELOW.

IF NO DOCUMENTATION PROVIDED ASK: How much did you receive in these benefits? IF UNSURE: Your best estimate is fine.

$ |___|___|,|___|___|___|

D36. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

D37. INTERVIEWER: RECORD D37 TO D42 IF DOCUMENTATION IS PROVIDED. IF NO DOCUMENTATION IS PROVIDED GO TO D43.

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

D38. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

D39. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|___|,|___|___|___|

AMOUNT NOT FOUND ON
DOCUMENT 99

D40. INTERVIEWER: RECORD THE CASE ID ON THE BENEFITS STATEMENT.

|___|___|___|___|___|___|___|___|___|___|___|___|

CASE ID NOT FOUND ON
DOCUMENT 99

D41. INTERVIEWER: DOES THE FDPIR BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

PROGRAMMING NOTE D10: ASK D42 IF DOCUMENTATION WAS NOT FOR THE APPLICATION MONTH (D41 ≠ 1)

D42. Is the amount we just discussed as the FDPIR payment about the same as, less than, or more than the payment received in [application month and year]?

ABOUT THE SAME 1

LESS 2

MORE 3

D43. Do you have your FDPIR EBT card that you can show me?

YES 1

NO 2

D44. INTERVIEWER: DID THE RESPONDENT SHOW A VALID FDPIR EBT CARD?

YES 1

NO 2

PROGRAMMING NOTE D11: AFTER CYCLING THROUGH QUESTIONS D33 THROUGH D44, APPLY THE FOLLOWING DELAYED SKIP PATTERN: IF HOUSEHOLD RECEIVES FDPIR BENEFITS (D33 = 1) GO TO SECTION I. THIS MEANS THE TARGET CHILD IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

SECTION E: HOUSEHOLD COMPOSITION

INTRO TO SECTION: Next, I would like to ask questions about the people who live here with you.

E1. I have your name recorded as [parent/guardian name]. Is this correct?

INTERVIEWER: SPELLING OF RECORDED NAME SHOULD BE CONFIRMED.

YES 1 (GO TO E3)

NO 2 (GO TO E2)

E2. May I please have the correct spelling of your name?

_________________________ _________________________

FIRST NAME LAST NAME

E3. How many people live with you not including yourself? Please include babies, small children, people who are not related to you and people who are temporarily away, for example, at school or in a hospital.

| | | PEOPLE LIVING IN HOUSEHOLD

E4. Please tell me the first name of everyone who lives here with you.

PROBE: Who else lives with you?

_________________________

RESPONDENT (NAME # 1)

_________________________

TARGET CHILD (NAME # 2)

_________________________

NAME # 3

_________________________

NAME # 4

_________________________

NAME # 5

_________________________

NAME # 6

_________________________

NAME # 7

_________________________

NAME # 8

_________________________

NAME # 9

_________________________

NAME # 10

_________________________

NAME # 11

_________________________

NAME # 12

_________________________

NAME # 13

_________________________

NAME # 14

PROGRAMMING NOTE E1: ALLOW AS MANY RECORDS AS NEEDED TO LIST ENTIRE HOUSEHOLD MEMBERSHIP. COMPLETE LOOP OF QUESTIONS E5 TO E12 FOR EVERY NAMED MEMBER OF THE HOUSEHOLD, INCLUDING THE RESPONDENT AND TARGET CHILD.

SKIP QUESTION E5 IF ASKING ABOUT THE RESPONDENT.

E5. What is [name’s] relationship to you?

BIOLOGIC OR NATURAL CHILD 1

STEPCHILD OR ADOPTED CHILD 2

OTHER CUSTODIAL CHILD 3

FOSTER CHILD 4

SPOUSE OR DOMESTIC PARTNER 5

BOYFRIEND, GIRLFRIEND, OR PARTNER 6

PARENT 7

STEPPARENT 8

GRANDPARENT OR GREAT GRANDPARENT 9

AUNT, UNCLE, GREAT AUNT, OR GREAT UNCLE 10

SIBLING (BROTHER OR SISTER) 11

NEPHEW OR NIECE 12

COUSIN 13

GRANDCHILD 14

OTHER RELATIVE OR IN-LAW 15

NON-RELATIVE (INCLUDING FRIEND, ROOMER

OR BOARDER) 16

OTHER (SPECIFY) ___________________ 17

E6. WHEN ASKING ABOUT RESPONDENT AND IF KNOWN, CODE WITHOUT ASKING. (Are you/Is [name]) male or female?

MALE 1

FEMALE 2

E7. What is (your/[name]’s) date of birth?

| | | / | | | / | | | | | (GO TO E9)

MONTH DAY YEAR

IF REFUSED OR DON’T KNOW, GO TO E8.

E8. How old (are you/is [name])?

| | | MONTHS

OR

| | | YEARS

PROGRAMMING NOTE E2: ASK E9 IF CALCULATED OR REPORTED AGE IS 12 YEARS OR YOUNGER. DO NOT ASK E9 for the target child.

E9. Is [name] currently receiving care at [name of sampled child care center]?

YES 1

NO 2

PROGRAMMING NOTE E3: ASK E10 IF CALCULATED OR REPORTED AGE IS 5 TO 20 YEARS.

E10. Is [name] currently attending school?

YES 1

NO 2 (GO TO E12)

PROGRAMMING NOTE E4: ASK E11, IF E10 = 1.

E11. What level of school is [name] in?

CHILD CARE CENTER 1

PRESCHOOL 2

KINDERGARTEN 3

ELEMENTARY 4

MIDDLE SCHOOL OR JUNIOR HIGH 5

HIGH SCHOOL 6

TRADE SCHOOL OR COLLEGE 7

E12. Did [name] live with you in [application month and year]?²

IF NEEDED, ADD: This is the month you provided your income on an application or in some other way to determine if [target child] was eligible for food program benefits at [name of sampled child care center].

YES 1

NO 2

PROGRAMMING NOTE E5: IF THERE IS ANOTHER PERSON ON THE HOUSEHOLD ROSTER, REPEAT QUESTIONS E5 TO E12 ABOUT THAT PERSON UNTIL INFORMATION IS COLLECTED FOR ALL PERSONS LISTED ON ROSTER.

PROGRAMMING NOTE E6: DISPLAY LIST WITH NUMBER AND NAMES OF ALL PERSONS ON HOUSEHOLD ROSTER

E13. You have just told me that [number of persons on household roster] person(s) live here with you. This includes [names of all reported persons]. Just to confirm, have you told me about everyone who lives here, including babies, small children, people who are not related to you and people who are temporarily away, for example, at school or in a hospital?

YES 1

NO 2 (GO BACK TO E4)

PROGRAMMING NOTE E7: IF E13 = 2, RETURN TO E4 TO ADD NAME OF MISSING PERSON TO HOUSEHOLD ROSTER AND ASK ALL QUESTIONS E5 TO E12 ABOUT ADDED PERSON OR PERSONS.

E14. Did anyone (else) not currently in this household live with you in [application month and year]?

IF NEEDED, ADD: This is the month you reported your income when [target child]’s eligibility was checked for the food program benefits at [name of sampled child care center].

YES 1 (GO TO E15)

NO 2 (GO TO PROGRAMMING NOTE E10)

E15. How many other people lived with you in [application month and year]?

| | | ADDITIONAL HOUSEHOLD MEMBERS

E16. Please tell me the first name(s) of the other (person/people) that lived with you in [application month and year] who no longer live here with you now.

___________________________

NAME OF OTHER PERSON # 1

___________________________

NAME OF OTHER PERSON # 2

___________________________

NAME OF OTHER PERSON # 3

PROGRAMMING NOTE E8: IF RESPONDENT REPORTS ADDITIONAL HOUSEHOLD MEMBERS IN QUESTIONS E14 – E16 ADD NEWLY REPORTED NAMES TO THE ROSTER AT E4 AND REPEAT QUESTIONS E5 – E12 FOR EACH APPLICABLE PERSON.

PROGRAMMING NOTE E9: IF RELATIONSHIP WAS REPORTED AS FOSTER CHILD (E5 = 4), GO TO E22.

PROGRAMMING NOTE E10: REPEAT E17 TO ASK ABOUT EACH CHILD LISTED ON ROSTER WITH A CALCULATED OR REPORTED AGE UNDER 18 YEARS AND NOT IDENTIFIED AS A FOSTER CHILD (E5 ≠ 4).

E17. In [application month and year]³, did you (or your spouse/partner) pay any household expenses or provide any financial support to [name of each child under 18 years who is not identified as a foster child]?

PROBE: This question refers to your own income and resources to financially support [name], not the income and resources of others, which we will ask about later.

YES 1

NO 2

PROGRAMMING NOTE E11: DISPLAY LIST OF ALL PERSONS ON HOUSEHOLD ROSTER WITH A CALCULATED OR REPORTED AGE OF 18 YEARS OR OVER.

E18. Based on the information you gave about people living in your household, these persons are considered to be adults by this study, meaning over the age of 18. INTERVIEWER READ LIST.

Does my list include everyone considered to be an adult in this household?

YES 1 (GO TO E19)

NO 2 (GO TO E4)

PROGRAMMING NOTE E12: ALLOW NAVIGATION BACK TO THE HOUSEHOLD ROSTER QUESTIONS SO THAT CORRECTIONS CAN BE MADE.

PROGRAMMING NOTE E13: CREATE A LIST OF ALL ADULT HOUSEHOLD MEMBERS (18 YEARS OR OLDER) AT Q E4 BUT EXCLUDE RESPONDENT AND HOUSEHOLD MEMBER REPORTED TO BE RESPONDENT’S SPOUSE (E5 = 5) OR PARTNER (E5 = 6). USE THIS LIST TO ASK Q E19 AND E20.

REPEAT E19 UNTIL IT IS ASKED ABOUT EACH ADULT HOUSEHOLD MEMBER ON THE CREATED LIST.

E19. In the [application month and year], did (you/you and your spouse/you and your partner) pay any household expenses or provide any financial support to [name of each household member on the created list]?

YES 1

NO 2

PROGRAMMING NOTE E14: REPEAT E20 TO ASK ABOUT EACH ADULT ON THE CREATED LIST ABOUT EACH CHILD WITH A CALCULATED OR REPORTED AGE LESS THAN 18 YEARS WHO IS NOT IDENTIFIED AS A FOSTER CHILD FROM ROSTER (E5 ≠ 4).

E20. In the [application month and year], did [name of each household member on the created list] pay any household expenses or provide any financial support to [name of child under 18 years and who is not identified as a foster child]?

YES 1

NO 2

PROGRAMMING NOTE E15: REPEAT E21 TO ASK ABOUT EACH ADULT ON THE CREATED LIST.

E21. In [application month and year], did [name of each household member on the created list] pay any household expenses or provide any financial support to you?

YES 1

NO 2

PROGRAMMING NOTE E16: GO TO SECTION F, UNLESS A PERSON LISTED ON THE HOUSEHOLD ROSTER IS REPORTED TO BE A FOSTER CHILD (E5 = 4), ELSE CONTINUE.

E22. Who has legal and financial responsibility for [name of foster child]?

SELECT NAME(S) FROM HOUSEHOLD ROSTER 1

SOMEONE OUTSIDE THE HOUSEHOLD 2

AN AGENCY 3

OTHER, SPECIFY ____________ 4

PROGRAMMING NOTE E17: IF E22=1, SHOW LIST OF NAMES FROM HOUSEHOLD ROSTER TO SELECT.

SECTION F: INCOME AND EARNING SOURCES

INTRO TO SUBSECTION: Now we ask you about sources of income and benefits you and your household may have each month. While these questions may seem personal, they are important to understanding the child and adult care food program application process and the needs of families whose children are enrolled [name of sampled child care center]. We want to assure you that all of your responses are kept strictly private.

PROGRAMMING NOTE F1: IF TARGET CHILD IS IDENTIFIED AS A FOSTER CHILD (E5 = 4) CONTINUE. ELSE, GO TO PROGRAMMING NOTE F2.

F1. How much is [target child]’s personal income in each month? By “personal income,” we mean money received for [target child]’s personal use.

$ | |,| | | |

PROGRAMMING NOTE F2: CREATE LIST OF ALL PERSONS FROM THE HOUSEHOLD ROSTER WITH A CALCULATED AGE (FROM DOB RECORDED AT E7) OR REPORTED AGE (FROM E8) OF 18 YEARS OR YOUNGER INCLUDING THE TARGET CHILD AND REPORTED TO HAVE FINANCIAL SUPPPORT FROM IDENTIFIED PARENT/GUARDIAN (E17 = 1). QUESTIONS F2 TO F7 SHOULD BE ASKED ABOUT ALL PERSONS ON THIS LIST BEGINNING WITH THE TARGET CHILD.

F2. During [application month and year], did ([target child]/[child’s name]) have any income from child support, Social Security, persons outside the household, or any other source? This is income paid directly to your child, not income that you collect yourself.

Do not include SNAP, which we will talk about later.

YES 1 (GO TO F3)

NO 2 (GO TO F7A)

F3. What was the source of that income? SELECT ALL THAT APPLY

CHILD SUPPORT 1 (ASK F4)

SOCIAL SECURITY OR DISABILITY SURVIVORS’

BENEFITS 2 (ASK F5)

PERSONS OUTSIDE THE HOUSEHOLD 3 (ASK F6)

OTHER, SPECIFY ____________ 4 (ASK F7)

PROGRAMMING NOTE F3: ASK QUESTIONS F4 TO F7 ONLY AS TRIGGERED BY RESPONSES TO QF3. ONCE THE AMOUNT IS COLLECTED FOR TRIGGERED FOLLOWUPS, GO TO QF7a.

F4. How much is received monthly in child support?

$ | |,| | | |

NOT APPLICABLE 99

F5. How much is received monthly in Social Security benefits?

$ | |,| | | |

NOT APPLICABLE 99

F6. How much is received monthly from persons outside the household?

$ | |,| | | |

NOT APPLICABLE 99

F7. How much is received monthly from the other sources, including WIC?

$ | |,| | | |

NOT APPLICABLE 99

PROGRAMMING NOTE F4: REPEAT QUESTIONS F2 TO F7 TO ASK ABOUT EACH CHILD ON THE LIST CREATED BEFORE F2 UNTIL INFORMATION IS COLLECTED ABOUT ALL CHILDREN LISTED BEFORE QUESTION F2.

PROGRAMMING NOTE F5: CREATE LIST OF PERSONS FROM THE HOUSEHOLD ROSTER WITH A CALCULATED (FROM DOB RECORDED AT E7) OR REPORTED AGE (FROM E8) OF 18 YEARS OR OLDER AND REPORTED TO HAVE FINANCIAL RESPONSIBILITY FOR CHILDREN IN THE HOUSEHOLD, NOT INCLUDING FOSTER CHILD (E17 =1 YES)

ADD TO THE LIST PERSONS FROM THE HOUSEHOLD ROSTER WITH LEGAL/FINANCIAL RESPONSIBILITY FOR A FOSTER CHILD (E22 =1).

THE PARENT/GUARDIAN RESPONDENT IS LISTED FIRST AND HIS/HER SPOUSE/DOMESTIC PARTNER SECOND FOLLOWED BY ALL OTHER HOUSEHOLD MEMBERS ON THE LIST.

QUESTIONS F7A TO F32 SHOULD BE ASKED ABOUT ALL PERSONS ON THIS LIST

INTERVIEWER: PROVIDE THE RESPONDENT WITH THE INCOME SOURCE SHOW CARD AS A REFERENCE SO THEY CAN FOLLOW ALONG AND SELECT APPLICABLE INCOME SOURCES.

INTRO TO SUBSECTION: Please refer to this show card and your completed household survey worksheet (if you had a chance to complete it) as we work through the next set of questions.

F7a. INTERVIEWER: DOES RESPONDENT HAVE A COMPLETED WORKSHEET AVAILABLE TO ANSWER THE REMAINING QUESTIONS IN THIS SECTION?

YES 1

NO 2

F7b. (Based on your worksheet and/or the income source card) please tell me the number that corresponds to the income sources or benefits payments that (you/[person’s name]) received during the [application month and year]?

PROGRAMMING NOTE F6: ALLOW UP TO 10 INCOME/BENEFITS SOURCES PER PERSON.

INTERVIEWER: CHECK THE BOX ASSOCIATED WITH EACH SOURCE TYPE FOR HOUSEHOLD INCOME AND BENEFIT PAYMENT TYPE ON SHOW CARD 1 REPORTED BY THE RESPONDENT.

☐ Source 01	☐ Source 08	☐ Source 15	☐ Source 22
☐ Source 02	☐ Source 09	☐ Source 16	☐ Source 23
☐ Source 03	☐ Source 10	☐ Source 17	☐ Source 24
☐ Source 04	☐ Source 11	☐ Source 18	☐ Source 25
☐ Source 05	☐ Source 12	☐ Source 19	☐ Source 26
☐ Source 06	☐ Source 13	☐ Source 20
☐ Source 07	☐ Source 14	☐ Source 21

INTERVIEWER: CONFIRM THAT REPORTING IS COMPLETE BY PROBING “ANYTHING ELSE?” UNTIL RESPONDENT CONFIRMS THERE IS NO OTHER SOURCE OF INCOME OR BENEFITS FOR RESPONDENT/PERSON’S NAME.

Q#	During the [application month and year], did (you/[person’s name]) …	Responses
F8	…work at a job for pay? PROGRAMMING NOTE F7: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 01 IS SELECTED in QF7b PROBE: If you have your own business, only include the salary you pay yourself as personal income or regular earnings. Do not include the business profits or losses. We will ask about that later.	YES 1 NO 2
INTRO TO NEXT SERIES OF QUESTIONS: The next questions are about other kinds of income (you/[person’s name]) may have received during [application month and year]. Did (you/[person’s name])…
F9	…receive income from unemployment compensation? PROGRAMMING NOTE F8: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 02 IS SELECTED in QF7b	YES 1 NO 2
F10	…receive income from worker’s compensation? PROGRAMMING NOTE F9: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 03 IS SELECTED in QF7b	YES 1 NO 2
F11	…receive income from strike benefits? PROGRAMMING NOTE F10: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 04 IS SELECTED in QF7b	YES 1 NO 2
F12	…receive income from Social Security or railroad retirement? PROGRAMMING NOTE F11: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 05 IS SELECTED in QF7b	YES 1 NO 2
F13	…receive income from private pensions, annuities, or survivor’s benefits? PROGRAMMING NOTE F12: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 06 IS SELECTED in QF7b	YES 1 NO 2
F14	…receive military cash benefits such as housing, food, or clothing allowances? Please do not include combat pay. PROGRAMMING NOTE F13: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 07 IS SELECTED in QF7b	YES 1 NO 2
F15	…receive income from Veteran’s benefits? PROGRAMMING NOTE F14: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 08 IS SELECTED in QF7b	YES 1 NO 2
F16	…receive government disability benefits from Supplemental Security Income or SSI? PROGRAMMING NOTE F15: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 09 IS SELECTED in QF7b	YES 1 NO 2
F17	…receive income from private disability benefits? PROGRAMMING NOTE F16: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 10 IS SELECTED in QF7b	YES 1 NO 2
F18	…receive alimony payments? PROGRAMMING NOTE F17: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 11 IS SELECTED in QF7b	YES 1 NO 2
F19	…receive child support payments? PROGRAMMING NOTE F18: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 12 IS SELECTED in QF7b PROBE: Do not include the child support payment you reported on earlier about [name of child/children].	YES 1 NO 2
F20	…receive income from interest and dividends? PROGRAMMING NOTE F19: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 13 IS SELECTED in QF7b	YES 1 NO 2
F21	…receive rental income, that is, income from others in the form of rent? PROGRAMMING NOTE F20: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 14 IS SELECTED in QF7b	YES 1 NO 2
F22	…receive profit or loss from (your/her/his) own nonfarm business, partnership, or professional practice? PROGRAMMING NOTE F21: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 15 IS SELECTED in QF7b PROBE: This is profit or loss not included in the salary you pay yourself as personal income or regular earnings.	YES 1 NO 2
F23	…receive profit or loss from (your/her/his) own farm business? PROGRAMMING NOTE F22: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 16 IS SELECTED in QF7b	YES 1 NO 2
F24	…receive financial aid to college students? Please exclude money used for tuition, books, and fees but include money used for room and board. PROGRAMMING NOTE F23: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 17 IS SELECTED in QF7b	YES 1 NO 2
F25	…receive regular payments or withdrawals from large awards or settlements? PROGRAMMING NOTE F24: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 18 IS SELECTED in QF7b PROBE: Include income from legal settlements, inheritance, or prize winnings.	YES 1 NO 2
F26	…receive income from regular contributions or support from persons outside the household, for example, cash gifts or other financial assistance from friends or family? PROGRAMMING NOTE F25: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 19 IS SELECTED in QF7b	YES 1 NO 2
F27	…receive any other income, such as, net royalties, income from trusts, 401k, prize winnings, or bonuses? PROGRAMMING NOTE F26: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 20 IS SELECTED in QF7b	YES 1 NO 2
F28	…receive general assistance, such as state disability assistance or general relief programs? Please do not include TANF or SNAP benefits, which we will ask about later. PROGRAMMING NOTE F27: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 21 IS SELECTED in QF7b	YES 1 NO 2
F29	…receive a housing subsidy? PROGRAMMING NOTE F28: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 22 IS SELECTED in QF7b PROBE: Do not include military housing subsidies.	YES 1 NO 2
F30	…receive black lung benefits? PROGRAMMING NOTE F29 AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 23 IS SELECTED in QF7b	YES 1 NO 2
F31	…receive any other kind of public assistance (not including TANF, SNAP, MEDICAID, OR FDPIR)? PROGRAMMING NOTE F30: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 24 IS SELECTED in QF7b	YES 1 NO 2
F32	IF QF31 IS YES, ASK: What kind of public assistance did (you/person’s name]) receive during [application month and year]? IF QF31 IS NO: GO TO SECTION G.	SPECIFY: _______________ ________________

PROGRAMMING NOTE F31: REPEAT QUESTIONS F7b TO F32 ABOUT NEXT PERSON ON THE LIST CREATED BEFORE F7a UNTIL INFORMATION IS COLLECTED ABOUT ALL LISTED PERSONS.

SECTION G: INCOME AND EARNING AMOUNTS

PROGRAMMING NOTE G1: RUN AN EXTRACTION ROUTINE ON RESPONSES TO QUESTIONS F8 TO F32 ABOUT EACH ADULT PERSON ON CREATED LIST BEFORE F8. PRESENT FOLLOW-UP QUESTIONS ABOUT ANY REPORTED SOURCE OF INCOME OR RECEIVED BENEFITS, THAT IS, THE RESPONSE IS = 1 (YES) BY A PERSON LISTED BEFORE F8 IN SAME ORDER AS QUERIED IN F8 TO F32. THEN DISPLAY APPROPRIATE FOLLOW-UP QUESTION TO GATHER ADDITIONALLY NEEDED DETAILS.

INTRO TO SECTION: Next, I would like to ask you about the different amounts of income you and the other adults in your household received from the sources you just reported. For each type of income, we will go over the income and look at your documents together so that we are sure we get the right amounts. We can take a short break now so you can collect the documentation. The types of documentation I would like to see are check stubs, paystubs, or last year’s income tax return for earnings from jobs, receipts for cash jobs, leave and earnings statements, business records, award letters, or statement summaries that accompany pension or benefit payments.

INTERVIEWER: WAIT FOR RESPONDENT TO COLLECT DOCUMENTS THEN CONTINUE ON TO ASK INCOME AND EARNING AMOUNTS SECTION QUESTIONING.

PROGRAMMING NOTE G2: BEGIN ROUTINE, STARTING WITH QUESTION G1 ONLY IF F8 = 1 FOR RESPONDENT OR THIS PERSON. ELSE, GO TO NEXT PERSON.

ASK ABOUT PAID JOBS FOR ALL ADULTS ON LIST CREATED AT THE START OF THIS SECTION BEFORE ASKING ABOUT OTHER REPORTED INCOME SOURCES FOR EACH ADULT.

INTRO PAID WORK INCOME: Previously, you told me that (you/[person’s name]) had earnings from paid jobs during [application month and year]. Let’s work together, using the documentation you have available, to document the total pay received the last time (you were/[person’s name}was) paid.

INTERVIEWER: WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.

G1. We need to record the amount of (your/[person’s name]’s) earnings from all paid jobs during [application month and year]. The amount I need is the gross, before taxes and other deductions. That is (your/[person’s name]’s) total pay, not the amount that was brought home. Please include tips, commissions, and regular overtime pay. Please do not include profits or losses from (your/[person’s name]’s) own farm or nonfarm business, partnership, or professional practice in the [application month and year]. How much did (you/[person’s name]) earn from a paid job during the [application month and year]?

PROBE: Your best estimate or an average for the month is fine.

IF APPROPRIATE, ADD: We can probably get that amount from the earnings statement. IF NEEDED, ADD: Do you have an earnings statement from [application month and year]?

INTERVIEWER: IF THE RESPONDENT HAS DOCUMENTATION OF ANNUAL PAY, SUCH AS A TAX RETURN, YOU CAN DIVIDE THAT NUMBER BY TWELVE TO ESTIMATE FOR THE MONTH.

IF DOCUMENTATION IS NOT AVAILABLE, ADD: Your best estimate is fine.

$ |___|___|,|___|___|___|

G2. How often are these earnings paid to (you/[person’s name])?

HOURLY 1 (GO TO G3)

DAILY 2 (GO TO G3)

WEEKLY 3 (GO TO G3)

EVERY 2 WEEKS 4 (GO TO G3)

BI-MONTHLY (TWICE A MONTH) 5 (GO TO G3)

MONTHLY 6 (GO TO G4)

QUARTERLY 7 (GO TO G4)

ANNUALLY 8 (GO TO G4)

OTHER, SPECIFY_________ 9 (GO TO G4)

G3. We need to record how many times (you were/[person’s name]) was paid during [application month and year]. IF APPROPRIATE, ADD: We can look at the document to get this information. Your best estimate is fine.

INTERVIEWER: IF RESPONDENT ANSWERS DON’T KNOW, A COMMENT MUST BE ENTERED FOR CLARIFICATION.

|___|___| TIMES PAID

G4. INTERVIEWER: WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT RESPONDENT’S/THIS PERSON’S EARNINGS FROM A PAID JOB?

YES 1 (GO TO G5)

NO 2 (GO TO G11)

G5. INTERVIEWER: WHAT TYPE OF DOCUMENT WAS PROVIDED? CODE ALL THAT APPLY

CHECK STUB OR PAYSTUB 1

INCOME TAX RETURN 2

RECEIPT FOR CASH JOB 3

LEAVE AND EARNINGS STATEMENT 4

BUSINESS RECORDS 5

AWARD LETTER 6

EXPENSE RECEIPT 7

OTHER, SPECIFY__________ 8

G6. DOES THE PAY STATEMENT REFLECT EARNINGS DURING THE [APPLICATION MONTH], THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

[APPLICATION MONTH] 1 (GO TO G9)

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

G7. Is the amount we just discussed as (your/[person’s name]’s) income from this paid job about the same as, less than, or more than your household income in [application month and year]?

IF NEEDED, ADD: I am asking you to compare your income amount on this paystub to the income from this job that was reported when [target child]’s eligibility was determined for the food program benefits at [name of sampled child care center].

ABOUT THE SAME 1 (GO TO G9)

LESS 2

MORE 3

IF DON’T KNOW OR REFUSED, GO TO G9

G8. What is your best estimate of the monthly difference in the amount (you/[person’s name]) received from this paid job during [application month and year]?

$ |___|___|,|___|___|___|

G9. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

| | | / | | | / | | |

MONTH DAY YEAR

NOT FOUND ON DOCUMENT 99

G10. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|,|___|___|___|

NOT FOUND ON DOCUMENT 99

G11. Did (you/[person’s name]) have any other paid jobs during [application month and year]?

YES 1 (GO TO PROGRAMMING

NOTE G3)

NO 2 (GO TO PROGRAMMING NOTE G3)

PROGRAMMING NOTE G3: REPEAT QUESTIONS G1 TO G11 IN A LOOP UNTIL RESPONSE TO G11 = 2 (NO).

PROGRAMMING NOTE G4: ASK ENTIRE SERIES OF QUESTIONS ABOUT ALL OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT PERSON ON CREATED LIST BEFORE F8 BEFORE CONTINUING TO ASK THE SAME SERIES FOR THE NEXT ADULT. QUERY EACH ADULT IN THE SAME ORDER USED PREVIOUSLY FOR THE PAID WORK QUESTIONS.

INTRO TO OTHER SOURCES OF INCOME: Previously, you told me about some other sources of income that you and other persons in your household received during [application month and year]. Again, let’s work together using the documentation you have available, to document the amounts (you/[person’s name]) received from these other sources.

INTERVIEWER: WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.

PROGRAMMING NOTE G5: ASK THIS QUESTION ONLY IF F9 = 1 (YES) through F32 = 1 (YES) FOR OTHER SOURCES OF INCOME. REPEAT QUESTIONS FOR EACH OTHER INCOME SOURCE REPORTED FOR EACH ADULT.

G12. How much income did (you/[person’s name]) receive from [income source, (e.g., unemployment compensation)] during [application month and year]?

PROBE: If income is received on a yearly or quarterly basis, use your best estimate for what amount it would be on a monthly basis.

INTERVIEWER: IF INCOME IS NOT A DIRECT PAYMENT, SUCH AS A SUBSIDY, THE RESPONDENT CAN PROVIDE THEIR BEST ESTIMATE OF THE DOLLAR VALUE OF THE SUBSIDY ON A MONTLY BASIS.

IF APPROPRIATE, ADD: We can probably get this this amount from the payment statement. IF NEEDED, ADD: Do you have a benefits statement from [application month and year]?

OR ADD: Your best estimate is fine.

$ |___|___|,|___|___|___|

G13. How often did you receive (your/[person’s name]’s) [other income source]?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

G14. INTERVIEWER: WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT (RESPONDENT’S/PERSON’S) [INCOME SOURCE, EXAMPLE: UNEMPLOYMENT COMPENSATION] PAYMENT?

YES 1

NO 2 (GO TO NOTE AT END OF THIS SECTION)

G15. DOES THE DOCUMENT REFLECT PAYMENT DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD??

APPLICATION MONTH 1 (GO TO G18)

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

G16. Is the amount we just discussed as (your/[person’s name]’s) payment from this [other income source] about the same as, less than, or more than the payment received in [application month and year]?

IF NEEDED, ADD: I am asking you to compare the payment amount on this statement to the payment from [other income source] that was reported when [target child]’s eligibility was checked for the food program benefits at [name of sampled child care center].

ABOUT THE SAME 1 (GO TO G18)

LESS 2

MORE 3

IF DON’T KNOW OR REFUSED, GO TO G18.

G17. What is your best estimate of the monthly difference in the amount (you/[person’s name]) received from this [other income source] during [application month and year]?

$ |___|___|,|___|___|___|

G18. INTERVIEWER: SPECIFY THE TYPE OF DOCUMENT.

STATEMENT 1

BENEFITS LETTER 2

CHECK STUB 3

OTHER, SPECIFY__________ 4

G19. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

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

MONTH DAY YEAR

NOT FOUND ON DOCUMENT 99

G20. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|,|___|___|___|

NOT FOUND ON DOCUMENT 99

PROGRAMMING NOTE G6: REPEAT THE LOOP OF G12 THROUGH G20 TO ASK ABOUT EACH ADULT PERSON FROM CREATED LIST BEFORE F7a AND WITH REPORTED INCOME FROM ANOTHER SOURCE IN QUESTIONS F8 THROUGH F32.

SECTION H: TOTAL MONTHLY INCOME

PROGRAMMING NOTE H1: RUN A CALCULATION OF ALL SOURCES OF REPORTED INCOME IN SECTIONS F AND G. POST CALCULATED TOTAL TO QUESTION H1.

H1. The computer just added up all the income sources you told me about and the total household income in [application month and year] (including the income of people no longer here) is [calculated total from all sources listed in sections F and G]. Does that sound about right?

YES 1 (GO TO SECTION I)

NO 2 (GO TO H2)

PROGRAMMING NOTE H2: ALLOW INSTRUMENT TO RETURN TO INCOME AMOUNT QUESTIONS TO MAKE CORRECTIONS.

H2. Since you believe that the total calculated by the computer is not right, let’s review each source that you told me about to correct the amounts.

INTERVIEWER: READ OR SHOW RESPONDENT EACH INCOME SOURCE AND AMOUNT AND MAKE ADJUSTMENTS WHERE NEEDED. WHEN REVIEW IS COMPLETE, CODE 1 TO CONTINUE.

CONTINUE 1

H3. The revised total income for MONTH is now [total from all sources listed in section F and G]. Does that sound right?

YES 1

NO 2 (RETURN TO H2 TO REPEAT REVIEW OF ALL SOURCES, REPEAT PROCESS UNTIL INCOME IS CORRECTED TO THE RESPONDENT’S SATISFACTION)

SECTION I: DEMOGRAPHIC CHARACTERISTICS

INTRO TO SECTION: I have just a few more questions about you.

I1. Are you currently married, living with a partner to whom you are not married, widowed, divorced, separated, or never married?

MARRIED 1

LIVING WITH PARTNER TO WHOM YOU ARE

NOT MARRIED 2

WIDOWED 3

DIVORCED 4

SEPARATED 5

SINGLE AND NEVER MARRIED 6

I2. What is the highest grade or level of school that you have completed?

LESS THAN HIGH SCHOOL 1

HIGH SCHOOL GRADUATE OR GED 2

ASSOCIATES DEGREE 3

BACHELORS DEGREE 4

MASTERS DEGREE 5

DOCTORATE (PhD) DEGREE 6

LAW DEGREE 7

MEDICAL (M.D.) DEGREE. 8

OTHER, SPECIFY __________ 9

I3. Do you consider yourself to be Hispanic or of Latino origin?

PROBE: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?

YES 1

NO 2

I4. Are you American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White? MARK ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

I5. Are you a United States citizen?

YES 1 (GO TO I7)

NO 2 (GO TO I6)

I6. How long have you lived in the United States?

PROBE: Include the total number of years/months living in the United States even if you did not live here continuously.

| | | YEARS

| | | MONTHS

OR

SINCE | | | | | YEAR

I7. Is [target child] Hispanic or of Latino origin?

PROBE: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?

YES 1

NO 2

I8. Is (she/he) American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White? MARK ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

I9. This is the end of the interview. Thank you very much for participating in our study.

INTERVIEWER: GIVE THE RESPONDENT THE $30.00 OR $50.00 INCENTIVE PAYMENT.

INCENTIVE PAYMENT PROVIDED:

YES 1

NO 2

INCENTIVE PAYMENT AMOUNT:

$30.00 for Interview 1

$50.00 for Interview and Income Documentation 2

TIME INTERVIEW ENDED: | | |:| | | AM 1

HOUR MINUTE PM 2

PROGRAMMING NOTE I1: AUTOMATICALLY RECORD TIME INTERVIEW INSTRUMENT IS ENDED.

1 See Westat Confidentiality Pledge.

2 This also refers to the month of eligibility determination for households that did not complete an application but are eligible for CACFP. For example, Head Start households will be asked about “enrollment month” in Head Start center. Eligibility for Head Start automatically makes a child eligible for free meals. This also applies to questions E14, E15, and E16.

3 This is defined as the month and year that household submitted the income eligibility application or eligibility was determined based on categorical eligibility or participation in certain benefit programs. This variable should be pre-loaded from data previously abstracted from sponsor or child care center records.

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