Individuals/Households - Households

APPENDIX D5. HOUSEHOLD SURVEY

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Third Access, Participation, Eligibility and Certification Study Series (APEC III)

HOUSEHOLD SURVEY

SUMMARY:

Field Data Collectors will conduct the household survey with parents/guardians of the target student from sampled schools. The sample will be selected from households who submitted an application. It will not include directly certified students.

After the recruitment packet is mailed to the parent/guardian household, the data collector will contact the sampled household to schedule an interview based on the parent/guardian availability. The data collector will confirm the date/time for the interview a few days prior to the scheduled interview date. The data collector will then conduct the interview with the parent/guardian. Unless a special exception is made, the interview will take place in the home. At the completion of the interview, the parent/guardian will receive an incentive payment of $30 for completing the survey, and an additional $20 if they also provide income documentation. Thus, the total incentive payment is up to $50.

Data Collectors will ensure that parents/guardians are informed 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 used in any way that could 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 0584-0530. 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 sources, gather and maintain the data needed, and complete and review the collection of information.

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. The data collection protocol is that the data collector will contact the respondent by phone and recruit the parent/guardian to participate in the study. By the time the interviewer comes to the house, the respondent has agreed to participate. This document only includes the survey questions and does not include any introductory/recruitment scripts that are used prior to data collection.

2. 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.

3. The CAPI program includes a feature for the data collector to add a comment to each question using a comment code.

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

5. All instructions or notes to the Data collector and/or Programmer are in ALL CAPS. These are not read to the respondent.

6. 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 [in a bracket] text.

7. Any words that should be emphasized to the respondent by the data collector are underlined.

8. In front of many questions is an indication of who is asked the question. This will help orient the reader to follow the various paths during the questionnaire.

9. At times boxes are used for instructions and directions. The wording in these boxes has been simplified to increase comprehension for the reader. When programmed for CAPI these instructions will become considerable more complicated.

10. Questions highlighted in yellow were not asked in the APEC II household survey.

Section G and H:

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

Section H:

12. 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 G.

• Unemployment compensation;

• worker’s compensation benefits;

• strike benefits;

• social security or railroad retirement income;

• public or private pensions, 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;

• regular payments or withdrawals from large awards or settlements;

• 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:

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

b. How often was the reported payment made?

c. 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 data collector will record the start and end date for the income period, and the year-to-date amount.

SECTION A: ENROLLMENT STATUS

TIME INTERVIEW BEGAN: | | |:| | |

HOUR MINUTE

AM 1

PM 2

Section A determines whether the student attended the [Target School]. If the student never attended the school during the school year or is deceased, no interview will be conducted. The interviewer will start section A once they are settled in the house and have gained permission to conduct the interview.

A1. CODE WITHOUT ASKING IF KNOWN OR ASK: Is [Target Student Name] male or female?

MALE 1

FEMALE 2

A2. Does [Target Student Name] currently attend [Target School]?

YES 1 (GO TO A5)

NO 2

A3. What school does (she/he) attend now?

SCHOOL NAME:

STREET ADDRESS:

CITY, STATE, ZIP CODE

STUDENT DROPPED OUT OF SCHOOL 1

STUDENT DECEASED 2 (GO TO A6)

A4. When did (she/he) stop attending [Target School]?

PROBE: Was that in the beginning, middle, or the end of the month? IF BEGINNING ENTER 5, IF MIDDLE ENTER 15, IF END ENTER 25.

|___|___| / |___|___| / |___|___| (GO TO A7)

MONTH DAY YEAR

A5. When did (she/he) begin attending [Target School] this school year?

PROBE: By “this school year” I mean the current school year 2017-2018.

PROBE: Was that in the beginning, middle, or the end of the month? IF BEGINNING ENTER 5, IF MIDDLE ENTER 15, IF END ENTER 25.

|___|___| / |___|___| / |___|___| (GO TO SECTION B)

MONTH DAY YEAR

FIRST DAY OF SCHOOL 1 (GO TO SECTION B)

NEVER ATTENDED THIS YEAR 2 (GO TO A7)

A6. I am very sorry to hear about your loss. Thank you for your time. We will not do an interview. INTERVIEWER TERMINATE INTERVIEW.

A7. We are only interested in talking to parents or guardians of the student who attended [Target School] this school year. We will not be able to conduct an interview with you. Thank you for your time.

SECTION B: PARTICIPATION IN SCHOOL BREAKFAST AND LUNCH PROGRAMS

Section B asks about the student’s participation in the school breakfast and/or lunch program during the most recent 5-day school week. This section also asks for those students who did not eat the school breakfast or lunch on any day that they attended school, why that is the case.

BOX BA

IF [TARGET STUDENT NAME] NO LONGER ATTENDING [TARGET SCHOOL] GO TO B13; ELSE CONTINUE.

ASK QUESTIONS B1 THROUGH B7 IF STUDENT IS CURRENTLY ATTENDING THE [TARGET SCHOOL].

B1. The next questions are about the meals [Target Student Name] eats at school.

I am going to ask about whether your child had a school breakfast or lunch each day during the last full week of school. I am referring to the meals provided under the School Breakfast and School Lunch Program. They are the meals that are on the menu for free or a single price, as opposed to individual foods, such as salads, meats, and desserts that are priced and bought separately.

CODE WITHOUT ASKING IF KNOWN:

B2. When was the last full week of school?

NOTE TO INTERVIEWER: PLEASE USE CALENDAR TO ASSIST.

LAST WEEK 1

FROM |___|___| / |___|___| TO |___|___| / |___|___|

MONTH DAY MONTH DAY

B3. Now please think about the last full week of school—that would be (Monday through Friday last week/from Monday—DATE to Friday—DATE).

Did your child attend school on:

PROBE: By attend school, we mean your child was at school all or part of the day.

NOTE TO INTERVIEWER: IF RESPONDENT MAKES A STATEMENT ABOUT THE ENTIRE WEEK, ENTER DATA FOR EACH DATE.

YES NO

a. Monday, DATE 1 2

b. Tuesday, DATE 1 2

c. Wednesday, DATE 1 2

d. Thursday, DATE 1 2

e. Friday, DATE 1 2

BOX BB

IF [TARGET SCHOOL] HAS A SCHOOL BREAKFAST PROGRAM, ASK B4; ELSE GO TO BOX BC.

FOR EACH DAY THE STUDENT ATTENDED SCHOOL ASK B4 THROUGH B7.

B4. Did [Target Student Name] eat breakfast at school (last DAY/on DAY, DATE)?

YES 1

NO 2 (GO TO BOX BC)

B5. Was that breakfast thru the School Breakfast program?

PROBE: The School Breakfast Program consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.

YES 1

NO 2

BOX BC

IF [TARGET SCHOOL] HAS A SCHOOL LUNCH PROGRAM, ASK B6; ELSE GO TO BOX BD.

FOR EACH DAY THE STUDENT ATTENDED SCHOOL ASK B6 AND B7.

B6. Did (she/he) eat lunch at school (last DAY/on DAY, DATE)?

YES 1

NO 2 (GO TO BOX BD)

B7. Was that lunch provided through the School Lunch Program?

PROBE: The School Lunch Program consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.

YES 1

NO 2

BOX BD

REPEAT B4 THROUGH B7 FOR ALL DAYS [TARGET STUDENT NAME] ATTENDED SCHOOL FOR THE WEEK.

NOTE TO READER: QUESTIONS ASKED ABOUT STUDENTS WHO DID NOT EAT A SCHOOL LUNCH OR BREAKFAST SOME OF THE TIME THAT WERE IN APEC II HAVE BEEN DELETED.

ASK B8 ABOUT [TARGET STUDENT NAME] WHO ATTENDED SCHOOL AT LEAST ONE DAY FOR THE WEEK AND DID NOT PARTICIPATE IN THE SCHOOL BREAKFAST PROGRAM ON ANY DAY THEY WERE IN SCHOOL.

B8. You just mentioned that [Target Student Name] did not eat breakfast provided by the School Breakfast Program on any day (she/he) attended school (last week/during the last week (she/he) went to school). Why didn’t (she/he) eat the school breakfast (last week/during that week)?

AFTER RESPONSE, SAY: Were there other reasons? (MARK ALL THAT APPLY)

EATS BREAKFAST AT HOME 1

BRINGS BREAKFAST FROM HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT BREAKFAST 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY CHILDREN EAT
SCHOOL BREAKFASTS 8

STUDENT DOES NOT EAT SCHOOL BREAKFAST
BECAUSE FRIENDS DO NOT EAT IT 9

NOT IN SCHOOL THAT WEEK/OUT SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD EARLY MORNING CLASSES THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR BREAKFAST………………………….. 14

OTHER (SPECIFY) 15

IF MORE THAN ONE ANSWER TO B8, ASK B9; ELSE GO TO B10.

B9. What is the most important reason (she/he) did not eat the school breakfast (last/that) week?

EATS BREAKFAST AT HOME 1

BRINGS BREAKFAST FROM HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT BREAKFAST 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY STUDENTS EAT
SCHOOL BREAKFASTS 8

STUDENT DOES NOT EAT SCHOOL BREAKFAST
BECAUSE FRIENDS DO NOT EAT IT 9

NOT IN SCHOOL THAT WEEK/OUT SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD EARLY MORNING CLASSES THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR BREAKFAST………………………….. 14

OTHER (SPECIFY) 15

ASK B10 ABOUT [TARGET STUDENT NAME] WHO ATTENDED SCHOOL AT LEAST ONE DAY FOR THE WEEK AND DID NOT PARTICIPATE IN SCHOOL LUNCH PROGRAM ON ANY DAY THEY WERE IN SCHOOL.

B10. You mentioned that [Target Student Name] did not eat the school lunch on any day (she/he) attended school. Why didn’t (she/he) get the school lunch (last week/during that week)?

AFTER RESPONSE, SAY: Were there any other reasons? (MARK ALL THAT APPLY).

PREFERS TO BRING LUNCH FROM HOME 1

EATS LUNCH AT HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT LUNCH 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY CHILDREN EAT
SCHOOL LUNCHES 8

STUDENT DOES NOT EAT SCHOOL LUNCH
BECAUSE FRIENDS DO NOT EAT IT 9

NOT IN SCHOOL THAT WEEK/SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD CLASSES DURING LUNCH PERIOD THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR LUNCH ……………..………………… 14

OTHER (SPECIFY) 15

IF MORE THAN ONE ANSWER TO B10, ASK B11; ELSE GO TO B12.

B11. What is the most important reason (she/he) did not eat the school lunch (last/that) week?

PREFERS TO BRING LUNCH FROM HOME 1

EATS LUNCH AT HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT LUNCH 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY CHILDREN EAT
SCHOOL LUNCHES 8

STUDENT DOES NOT EAT SCHOOL LUNCH
BECAUSE FRIENDS DO NOT EAT IT 9

NOT IN SCHOOL THAT WEEK/OUT SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD CLASSES DURING LUNCH PERIOD THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR LUNCH………………………………… 14

OTHER (SPECIFY) 15

B12. INTERVIEWER: DID THE [TARGET STUDENT NAME] HELP THE RESPONDENT WITH THE QUESTIONS ON MEALS EATEN AT SCHOOL?

YES 1 (GO TO SECTION C)

NO 2 (GO TO SECTION C)

INTERVIEWER: ASK B13 AND B14 IF [TARGET STUDENT NAME] NO LONGER ATTENDS THE [TARGET SCHOOL].

B13. I am going to ask you how often your child usually had school breakfast or lunch each week when [Target Student Name] was going to [Target School]. By school breakfast or lunch, I mean the meals your child’s school provides to students under the School Breakfast and School Lunch Program. School meals are meals that include a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods such as salads, meats, or desserts that are priced and bought separately.

When [Target Student Name] was going to [Target School], how many days in an average week did (he/she) eat a school breakfast?

|___|

NUMBER OF DAYS ATE SCHOOL BREAKFASTS

NONE, DID NOT EAT BREAKFAST/
SCHOOL BREAKFAST 0

B14. When [Target Student Name] was going to [Target School], how many days in an average week did (he/she) eat a school lunch?

|___|

NUMBER OF DAYS ATE SCHOOL LUNCHES

NONE, DID NOT EAT LUNCH/
SCHOOL LUNCH 0

SECTION C: PERCEPTIONS OF SCHOOL MEALS

Section C asks the parent/guardian about the student’s perception of school meals as well as the parent/guardian’s perception of the school meals. As a reminder, ‘don’t know’, ‘refused’ and ‘add comment’ will be programed as a response option for all questions.

The next questions are about [Target Student Name]’s satisfaction with school breakfast meals at [Target School].

	Regarding the school breakfast meals at [Target School], how satisfied is/was [Target Student Name] with…	RESPONSE
C1a.	how the food tasted? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C1b.	the amount of food served? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C1c.	the school breakfast meal program overall? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5

The next questions are about [Target Student Name]’s satisfaction with school lunch meals at [Target School].

	Regarding the school lunch meals at [Target School], how satisfied is/was [Target Student Name] with…	RESPONSE
C1d.	how the food tasted? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C1e.	the amount of food served? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C1f.	the school lunch meal program overall? Was (she/he) …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5

The next questions are about your satisfaction with school breakfast meals at [Target School].

	Regarding the school meals at [Target School], how satisfied are/were you with …	RESPONSE
C2a.	the healthfulness of the food [Target Student Name] is/was served at school? Are/Were you …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C2b.	The school breakfast meal program overall? Are/Were you …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5

The next questions are about your satisfaction with school lunch meals at [Target School].

	Regarding the school lunch meals at [Target School], how satisfied are/were you with …	RESPONSE
C2c.	the healthfulness of the food [Target Student Name] is/was served at school? Are/Were you …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5
C2d.	The school lunch meal program overall? Are/Were you …	Very Satisfied 1 Somewhat satisfied 2 Somewhat dissatisfied 3 Very Dissatisfied 4 Student Never Eats Meals 5

C3. INTERVIEWER: DID THE [TARGET STUDENT NAME] HELP THE RESPONDENT WITH THE QUESTIONS ON MEALS EATEN AT SCHOOL?

YES 1

NO 2

SECTION D: PERCEPTIONS OF THE HOUSEHOLD APPLICATION

Section D asks several questions related to the perceived difficulty in completing the school breakfast and school lunch application.

Next, I would like to ask questions about the application you filled out for the school meal programs.

ASK TO EVERYONE.

D1. How easy or difficult was it for you to complete the application? Was it….

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

D2. Were you able to fill out the application in the language of your choice?

YES 1 (GO TO D4)

NO 2

D3. What would you say is your preferred language?

English 1

Spanish 2

Chinese (e.g. Mandarin or Cantonese) 3

French 4

Tagalog 5

Vietnamese 6

Korean 7

Arabic 8

Russian 9

Other (specify) _______________ 10

D4. How did you complete the application?

Hardcopy/Paper 1

Electronic, submitted hardcopy 2

Electronic, submitted via email 3

Electronic, submitted online 4

Interview, in person 5

Interview, by phone 6

D5. Did you need assistance to complete the application?

YES 1

NO … 2 (GO TO SECTION E)

D6. Did you request assistance to complete the application?

YES 1

NO … 2 (GO TO SECTION E)

D7. Did you receive assistance to complete the application?

YES 1

NO …. 2 (GO TO SECTION E)

D8. Who did you try and contact for assistance? (TITLE OF PERSON, DO NOT RECORD NAMES)

___________________________

D9. Who provided the assistance?

___________________________ (TITLE OF PERSON, DO NOT RECORD NAMES)

D10. What type of assistance did you receive?

SECTION E: CATEGORICAL ELIGIBILITY

Section E asks a series of questions to determine if the target student was categorically eligible for free meals. Households that are categorically eligible are not required to complete household size and income questions as part of the application or this survey.

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

INTERVIEWER NOTE: READ THE FIRST THREE RESPONSE OPTIONS FOR E1. IF THE RESPONDENT DOES NOT SELECT ONE OF THE FIRST THREE RESPONSE OPTIONS, CONTINUE READING RESPONSE OPTIONS UNTIL THE RESPONDENT PROVIDES AN ANSWER.

E1. What is [Target Student Name]’s relationship to you?

BIOLOGICAL CHILD 1

STEPCHILD OR ADOPTED CHILD 2

OTHER CUSTODIAL CHILD 3

FOSTER CHILD 4

SPOUSE OR DOMESTIC PARTNER 5

BOYFRIEND, GIRLFRIEND,OR PARTNER 6

AUNT OR UNCLE 7

SIBLING (BROTHER OR SISTER) 8

NEPHEW OR NIECE 9

COUSIN 10

GRANDCHILD 11

OTHER RELATIVE 12

NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 13

OTHER (SPECIFY) 14

E2. CODE WITHOUT ASKING (BASED ON RESPONSE FROM A1): [Target Student Name]’s GENDER:

MALE 1

FEMALE 2

E3. What is [Target Student Name]’s date of birth?

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

MONTH DAY YEAR

E4. Did [Target Student Name] live with you in [Application Month, Year]?

YES 1

NO 2

BOX EA

IF [TARGET STUDENT NAME] IS A FOSTER CHILD (E1 = 4) GO TO SECTION J.

[TARGET STUDENT NAME] IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

HOUSEHOLD BENEFITS

The next questions are about benefits received through government programs. Soon we’ll need to look at any documentation you have about payments from these programs. Do you have that ready?

INTERVIEWER: IF NO, GIVE TIME FOR RESPONDENT TO COLLECT DOCUMENTATION WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.

TANF BENEFITS

Let’s discuss TANF benefits. 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.

E5 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 [State Name for TANF]?

YES 1

NO 2 (GO TO E18)

E6. 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 with [application month and year]?

YES 1

NO 2 (GO TO E14)

E7. 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.

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

E8. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

INTERVIEWER: COMPLETE E9-E13 IF DOCUMENTATION IS PROVIDED. IF NO DOCUMENTATION PROVIDED GO TO E15.

E9. INTERVIEWER: RECORD TYPE OF DOCUMENT.

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

E10. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

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

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

E11. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

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

AMOUNT NOT FOUND ON
DOCUMENT 99

E12. INTERVIEWER: DOES THE TANF BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1 (GO TO J1)

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

ASK IF E12 DOES NOT=1,

E13. 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

E14. Do you have your TANF EBT card, also known as STATE NAME FOR TANF card, that you can show me?

YES 1

NO 2

E15. INTERVIEWER: DID THE RESPONDENT SHOW A VALID TANF CARD?

YES 1

NO 2

E16. Does anyone else in your household receive TANF under a different case number?

YES………………………………………..1

NO ……2 (GO TO E18)

E17 Do you share housing, income, or expenses with this person?

YES………………………………………..1

NO ……2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES TANF BENEFITS (E5 = 1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

SNAP BENEFITS

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

E18. 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 [State Name for SNAP]

YES 1

NO 2 (GO TO E31)

E19. 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 [application month and year]?

YES 1

NO 2 (GO TO E27)

E20. 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.

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

E21. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

INTERVIEWER: COMPLETE E22 TO E26 IF DOCUMENTATION IS PROVIDED. IF NO DOCUMENTATION IS PROVIDED GO TO E27.

E22. INTERVIEWER: RECORD TYPE OF DOCUMENTATION:

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

E23. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

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

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

E24. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

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

AMOUNT NOT FOUND ON
DOCUMENT 99

E25. INTERVIEWER: DOES THE SNAP BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1 (GO TO J1)

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

ASK IF E25 DOES NOT= 1

E26. 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

E27. Do you have your SNAP EBT card, also known as STATE NAME FOR SNAP card, that you can show me?

YES 1

NO 2

E28. INTERVIEWER: DID THE RESPONDENT SHOW A VALID SNAP CARD?

YES 1

NO 2

E29. Does anyone else in your household receive SNAP under a different case number?

YES………………………………………..1

NO 2 (GO TO E31)

E30. Do you share housing, income, or food expenses with this person?

YES………………………………………..1

NO ……2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES SNAP BENEFITS (E18= 1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

OTHER BENEFITS

E31. During [application month and year], did you, your spouse, and/or child/children participate in the Food Distribution Program for Indian Reservations (FDPIR)? 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 E42 IF APPLICABLE, OTHERWISE GO TO SECTION F)

PROGRAMMER NOTE: STATES PARTICIPATING IN MEDICAID DEMONSTRATION PROGRAM WILL BE FLAGGED AND RESPONDENTS WILL BE DIRECTED TO E42 IF ELIGIBLE

E32. 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 E40)

E33. 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.

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

E34. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 5

INTERVIEWER: RECORD E35 TO E39 IF DOCUMENTATION IS PROVIDED. IF NO DOCUMENTATION IS PROVIDED GO TO E40.

E35. INTERVIEWER: RECORD THE TYPE OF DOCUMENTATION:

STATEMENT/NOTIFICATION 1

BENEFITS STATEMENT 2

CHECK STUB 3

OTHER (SPECIFY) 4

E36. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.

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

MONTH DAY YEAR

END DATE NOT FOUND ON
DOCUMENT 99

E37. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

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

AMOUNT NOT FOUND ON
DOCUMENT 99

E38. INTERVIEWER: DOES THE FDPIR BENEFITS STATEMENT REFLECT AMOUNT PAID DURING THE APPLICATION MONTH, THE CURRENT MONTH, OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1 (GO TO J1)

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

ASK IF E38 DOES NOT =1

E39. 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

E40. Do you have your FDPIR EBT card, that you can show me?

YES 1

NO 2

E41. INTERVIEWER: DID THE RESPONDENT SHOW A FDPIR EBT CARD?

YES 1

NO 2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES FDPIR BENEFITS (E31 = 1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

PROGRAMMER NOTE: ONLY ASK SECTION ON MEDICAID IF STATE USES MEDICAID AS A MEANS TO DIRECTLY CERTIFY STUDENTS FOR RECEIPT OF FREE MEALS. A LIST OF STATES PARTICIPATING IN DEMONSTRATION PROGRAM WILL BE PROVIDED.

E42. Did you, your spouse, and/or child/children receive Medicaid benefits during [application month and year]?

YES 1

NO ...2 (GO TO SECTION F)

E43. 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 SECTION J)

E44. INTERVIEWER: RECORD TYPE OF DOCUMENT.

MEDICAID CARD 1

OTHER DOCUMENTATION 2

PROGRAMMER NOTE: IF STATE USES MEDICAID AS A MEANS TO DIRECTLY CERTIFY STUDENTS FOR RECEIPT OF FREE MEALS AND HOUSEHOLD RECEIVES MEDICAID, GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

SECTION F: HOUSEHOLD COMPOSITION

Section F asks a series of questions to determine the composition of who currently lives in the household. For each person identified, a series of questions are asked about that person including relationship to the respondent, gender, age, grade level for children and occupation for adults. In this section, we also ask if anyone else lived in the household during the application month.

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

ASK TO EVERYONE.

F1. I have your name recorded as [parent/guardian name]. Is this correct?

INTERVIEWER: SPELLING OF RECORDED NAME SHOULD BE CONFIRMED.

YES 1 (GO TO F3)

NO 2 (GO TO F2)

F2. May I please have the correct spelling of your name?

FIRST NAME LAST NAME

F3. Not 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, for example, at school or in a hospital.

|___|___|

PEOPLE LIVING IN HOUSEHOLD

NONE OR LIVES ALONE 1 (GO TO F14)

F4. CODE IF KNOWN OR ASK: Does [Target Student Name] live with you?

YES 1

NO 2

F5. Please tell me the first name of everyone who lives here with you.

FILL IN NAME OF RESPONDENT IN POSITION #1 .

PROBE: Who else lives with you?

________________________ RESPONDENT (NAME # 1)	________________________ NAME # 6	________________________ NAME # 11
________________________ NAME # 2	________________________ NAME # 7	________________________ NAME # 12
________________________ NAME # 3	________________________ NAME # 8	________________________ NAME # 13
________________________ NAME # 4	________________________ NAME # 9	________________________ NAME # 14
________________________ NAME # 5	________________________ NAME # 10	________________________ NAME # 15

BOX FA

PROGRAMMER NOTE: ALLOW AS MANY RECORDS AS NEEDED TO LIST ENTIRE HOUSEHOLD MEMBERSHIP. QUESTIONS F6-12 WILL BE ASKED OF EVERY MEMBER OF THE HOUSEHOLD, EXCEPT [TARGET STUDENT NAME] WHICH WAS ASKED IN SECTION E.

SKIP QUESTION F6 WHEN ASKING ABOUT THE RESPONDENT.

NOTE TO READER: FOR DEMONSTRATION PURPOSES QUESTIONS F6 THROUGH F12 ARE SHOWN FOR 3 HOUSEHOLD MEMBERS. WHEN PROGRAMMED, THESE QUESTIONS WILL LOOP TO BE ASKED OF ALL HOUSEHOLD MEMBERS.

RECORD RESPONDENT FIRST THEN RECORD NAMES OF ALL OTHER HOUSEHOLD MEMBERS ACROSS THE GRID FIRST, THEN ASK F6 THROUGH F12 FOR EACH PERSON.

	____________________ RESPONDENT	____________________ NAME #2	____________________ NAME #3
F6. What is NAME's relationship to you?		BIOLOGICAL 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 ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17	BIOLOGICAL 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 ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
F7. CODE GENDER. IF NECESSARY, ASK: Is NAME female or male?	FEMALE 1 MALE 2	FEMALE 1 MALE 2	FEMALE 1 MALE 2
F8. What is (her/his) date of birth?	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated
F9. How old is (he/she)?	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|
IF AGE IS AGE 5-18, ASK F10; OTHERWISE, SKIP TO F12. F10. Is [name] currently attending school?	YES 1 NO 2 (GO TO F12)	YES 1 NO 2 (GO TO F12)	YES 1 NO 2 (GO TO F12)
F11. What grade is (she/he) attending?	|___|___| GRADE OR PRESCHOOL p KINDERGARTEN k ELEMENTARY e MIDDLE m HIGH SCHOOL h IN COLLEGE c UNGRADED u	|___|___| GRADE OR PRESCHOOL p KINDERGARTEN k ELEMENTARY e MIDDLE m HIGH SCHOOL h IN COLLEGE c UNGRADED u	|___|___| GRADE OR PRESCHOOL p KINDERGARTEN k ELEMENTARY e MIDDLE m HIGH SCHOOL h IN COLLEGE c UNGRADED u
F12. Did [name] live with you in [application month]?	YES 1 NO 2	YES 1 NO 2	YES 1 NO 2
	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)

BOX FB

DISPLAY LIST WITH NUMBER AND NAMES OF ALL PERSONS ON HOUSEHOLD ROSTER.

ASK OF EVERYONE

F13. 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 (RETURN TO F5 AND

ADD NAMES TO THE

HOUSEHOLD ROSTER)

F14. For this next question, do not include temporary visitors. Did anyone (else) live with you in this household in [application month and year] that does not live with you now?

IF NEEDED, ADD: This is the month you reported your income when [Target Student Name]’s eligibility was checked for the food program benefits at [Target School].

YES 1 (GO TO F15)

NO 2 (GO TO BOX FD)

F15. How many other people lived with you in [application month and year]?

|___|

ADDITIONAL HOUSEHOLD MEMBERS

F16. 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

BOX FC

FOR EACH ADDITIONAL HOUSEHOLD PERSON RECORDED IN F16, LOOP BACK TO F5 AND ASK F6 TO F12 FOR EACH NAME. THEN GO TO BOX FD.

BOX FD

IF RESPONSE WAS “YES” TO RECEIVING EITHER TANF BENEFITS, SNAP BENEFITS, FDPIR BENEFITS OR MEDICAID CONTINUE TO SECTION J, ELSE CONTINUE

ASK F17 TO F19 FOR EACH PERSON LISTED ON ROSTER UNDER AGE 18 AND NOT A FOSTER CHILD.

F17. In [application month and year], did you (or your spouse/partner) pay any household expenses or provide any financial support to [name of each child under age of 18 who is not identified as a foster child]? 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

DISPLAY LIST OF ALL PERSONS ON HOUSEHOLD ROSTER AGE 18 AND OLDER.

F18. Based on the information you gave about people living in your household, these persons are considered to be adults by this study, meaning ages 18 and older. INTERVIEWER READ LIST.

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

YES 1

NO 2 (RETURN TO F5)

BOX FE

REPEAT F19 FOR EACH CHILD UNDER THE AGE OF 18 IN THE HOUSEHOLD.

F19. 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 [Child Under The Age Of 18]?

YES 1

NO 2

BOX FF

CREATE A LIST OF ALL ADULT HOUSEHOLD MEMBERS EXCLUDING THE RESPONDENT AND THE RESPONDENTS SPOUSE OR PARTNER. USE THIS LIST TO ASK F20 AND F21.

REPEAT F20 TO F21 UNTIL EACH ADULT HOUSEHOLD MEMBER ON THE CREATED LIST IS ASKED ABOUT EACH CHILD UNDER THE AGE OF 18.

F20. In the [application month and year], did [name of each household member on the created list (referenced in box above)] pay any household expenses or provide any financial support to [name of child under 18 years]?

YES 1

NO 2

F21. 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

F22. ASK F23 ONLY IF THE RELATIONSHIP TO THE RESPONDENT IS FOSTER CHILD

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

SECTION G: INCOME AND EARNING SOURCES

In Section G we ask about the sources of income and benefits for the household.

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 school meal program application process and the needs of families whose children are enrolled in the [Target School District Name] school district. We want to assure you that all of your responses are kept strictly private.

BOX GA

CREATE LIST OF ALL PERSONS FROM THE HOUSEHOLD ROSTER WITH A CALCULATED AGE LESS THAN 18 YEARS OF AGE (INCLUDING THE [TARGET STUDENT NAME]) AND REPORTED TO HAVE FINANCIAL SUPPORT FROM PARENT/GUARDIAN.

ASK G1-G6 OF EACH CHILD UNDER THE AGE OF 18 WHO HAD FINANCIAL SUPPORT FROM THE PARENT OR GUARDIAN.

G1. During [application month and year], did ([[Target Student Name]]/[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.

YES 1

NO 2 (GO TO BOX GB)

G2. What was the source of that income? SELECT ALL THAT APPLY

PROBE: Were there any other sources of income?

CHILD SUPPORT 1 (ASK G3)

SOCIAL SECURITY OR DISABILITY
SURVIVORS’ BENEFITS 2 (ASK G4)

PERSONS OUTSIDE THE
HOUSEHOLD 3 (ASK G5)

OTHER, SPECIFY 4 (ASK G6)

G3. How much is received monthly in child support?

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

G4. How much is received monthly in Social Security benefits or disability survivors benefits?

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

G5. How much is received monthly from persons outside the household?

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

G6. How much is received monthly from the other sources?

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

REPEAT G1 TO G6 FOR ALL CHILDREN IN CREATED LIST CREATED IN BOX GA.

BOX GB

CREATE LIST OF PERSONS FROM THE HOUSEHOLD ROSTER MEETING THE FOLLOWING CRITERIA:

• AN AGE OF 18 OR OLDER AND REPORTED TO HAVE FINANCIAL RESPONSIBILITY FOR CHILDREN IN THE HOUSEHOLD.

ASK G8 TO ALL NAMES ON CREATED LIST.

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

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.

G7. INTERVIEWER: DOES RESPONDENT HAVE A COMPLETED WORKSHEET AVAILABLE TO ANSWER THE REMAINING QUESTIONS IN THIS SECTION?

YES 1

NO 2

ASK G8 FOR EACH ADULT CREATED IN BOX GB.

G8. Let’s review each source of income listed on your worksheet. Looking at the worksheet during the [application month and year], did you receive [SOURCE 1] income for paid work?

YES 1

NO 2

INTERVIEWER: IF THE RESPONDENT HAS NOT COMLETED THE WORKSHEET AHEAD OF TIME, USE THE SHOWCARD TO GO THROUGH EACH INCOME SOURCE OPTION. ASK ABOUT EACH SOURCE OF INCOME ON THE WORKSHEET/CARD. RECORD EACH SOURCE TYPE FOR HOUSEHOLD INCOME AND BENEFIT PAYMENT ON WORKSHEET/SHOW CARD REPORTED BY THE RESPONDENT.

PROGRAMMER NOTE: PROVIDE YES OR NO RESPONSES FOR SOURCES 1-25.

SOURCE #	TYPE OF INCOME OR BENEFITS PAYMENT
Source 1	Income for paid work 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. For military service members, include Military Basic Pay. For deployed service members, include only the amount made available to the household.
Source 2	Unemployment Compensation Money that substitutes for wages or salary, paid to recently unemployed workers under a program administered by a government or labor union.
Source 3	Workers Compensation Benefits Payment that is required by law to be made to an employee who is injured or disabled in connection with work.
Source 4	Strike Benefits Money paid to strikers by a union to enable them to be supported during a strike.
Source 5	Social Security or Railroad Retirement Railroad retirement program provides retirement, survivor unemployment and sickness benefits to individuals who have spent a substantial portion of their career in railroad employment, as well as to workers’ families. Social Security Retirement is a federal insurance program that provides benefits to retired people and those who are unemployed or disabled.
Source 6	Pensions (public or private), Annuities, or Survivor’s Benefits A pension is a fund into which a sum of money is added during an employee's employment years, and from which payments are drawn to support the person's retirement from work in the form of periodic payments. An annuity is a contract between you and an insurance company that requires the insurer to make payments to you, either immediately or in the future. You buy an annuity by making either a single payment or a series of payments. Similarly, your payout may come either as one lump-sum payment or as a series of payments over time. Survivor's benefits are for widows and widowers receiving monthly Social Security benefits based on their deceased spouse’s earnings records.
Source 7	Military Cash Benefits Cash benefits for housing, food, or clothing allowances, including the Basic Allowance for Housing (BAH). Do not include combat pay, or benefits from the Family Substance Supplemental Allowance (FSSA) or the Military Housing Privatization Initiative (MHPI). For deployed service members, only include the amount made available to the household.
Source 8	Veteran’s Benefits Benefits you receive based on military service.
Source 9	Government Disability Benefits from Supplementary Security Income (SSI) SSI program pays benefits to disabled adults and children who have limited income and resources.
Source 10	Private Disability Benefits Providing benefits to employees who are unable to work due to disability, by paying all or part of their salaries from an insurance policy that can be provided by an employer as an employee benefit, or an insurance policy that can be purchased by an individual directly from an insurance company.
Source 11	Alimony Payments Payments made in a lump sum or on a continuing basis to provide financial support to a spouse before or after a marital separation or divorce. Alimony does NOT include child support, noncash property settlements, payments to keep up the payer’s property or use of the payer’s property.
Source 12	Child Support Payments Ongoing payment made by a parent to contribute to the costs of raising her or his child following the end of a marriage or other relationship.
Source 13	Interest and Dividends Income A dividend is a distribution of a portion of a company's earnings, decided by the board of directors, to a class of its shareholders. Dividends can be issued as cash payments, as shares of stock, or other property. Interest earned on investments is interest income.
Source 14	Net rental income The amount someone pays you to use your property, after you subtract the expenses you have for the property.
Source 15	Profit or Loss from Nonfarm Business, Partnership, or Professional Practice This is profit or loss not included in the salary you pay yourself as personal income or regular earnings.
Source 16	Profit or Loss from a Farm Income gained or loss from growing crops, raising livestock, breeding fish or operating a ranch.
Source 17	Financial Aid to College Students Include money used for room and board, do NOT exclude money used for tuition, books, and fees or Pell Grants, Supplemental Education Opportunity Grants, State Student Incentive Grants, National Direct Student Loans, PLUS, College Work Study, or Byrd Honor Scholarship Programs.
Source 18	Regular Payments or Withdrawals from Large Awards or Settlements Include income from legal settlements, inheritance, prize winnings, or bonuses.
Source 19	Regular Contributions from Persons Outside the Household Include cash gifts or other financial assistance from friends or family.
Source 20	Other Income, such as Net Royalties, Trust Income, or 401K.
Source 21	General Assistance Benefits State or county programs serving low-income individuals who do not have minor children, are not disabled enough to qualify for (or do not yet receive) Supplemental Security Income (SSI), and are not elderly.
Source 22	Housing Subsidy (do not include Federal housing subsidies) Subsidized housing is owned and operated by private owners who receive subsidies in exchange for renting to low- and moderate-income people. Owners may be individual landlords or for-profit or nonprofit corporations. This does not include subsidized housing programs overseen by the U.S. Dept. of Housing and Urban Development (HUD) such as Section 8 or the Rural Rental Assistance program is managed by the USDA.
Source 23	Federal Black Lung Program Provides compensation to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment, and to survivors of coal miners whose deaths are attributable to the disease and provides eligible miners with medical coverage for the treatment of lung diseases related to pneumoconiosis.
Source 24	Other Public Benefits, not including TANF or SNAP Other benefits such as Women, Infants and Children (WIC) or State Children’s Health Insurance (SCHIP) Do not include TANF or SNAP benefits.
Source 25	Select if person has no source of income or benefits.

INTERVIEWER:

CONFIRM THAT REPORTING IS COMPLETE BY PROBING:

IS THERE ANY OTHER SOURCE OF INCOME THAT WASN’T MENTIONED ON YOUR WORKSHEET? ASK UNTIL RESPONDENT CONFIRMS THERE IS NO OTHER SOURCE OF INCOME OR BENEFITS FOR RESPONDENT/PERSON’S NAME.

IF YES, SPECIFY AND RECORD. THIS SOURCE WILL BE INCLUDED IN SECTION H.

REPEAT FOR EACH PERSON ON LIST, UNTIL INFORMATION IS COLLECTED FOR ALL LISTED PERSONS.

SECTION H: INCOME AND EARNING AMOUNTS

Section H records and documents all income sources in the application month for all incomes and benefits reported in Section G.

BOX HA

CREATE LIST OF ALL RESPONDENTS AGE 18 AND OLDER WITH AT LEAST ONE SOURCE OF INCOME OR BENEFITS AS REPORTED IN SECTION G.

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 you reported, 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.

ASK H1-H11 FOR EACH ADULT HOUSEHOLD MEMBER WHO HAD INCOME FOR A PAID JOB (SOURCE #1). ELSE GO TO BOX HC.

You just 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 during [application month and year].

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

H1. 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 which 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]?

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]?

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

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

H2. How often are these earnings paid to (you/[person’s name])?

HOURLY 1 (GO TO H3)

DAILY 2 (GO TO H3)

WEEKLY 3 (GO TO H3)

EVERY 2 WEEKS (BI-WEEKLY) 4 (GO TO H3)

TWICE A MONTH 5 (GO TO H3)

MONTHLY 6 (GO TO H4)

QUARTERLY 7 (GO TO H4)

ANNUALLY 8 (GO TO H4)

OTHER, SPECIFY 9 (GO TO H4)

ASK IF H2 = DON’T KNOW

H3. 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 earnings statement 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

H4. INTERVIEWER: WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT THIS PERSON’S EARNINGS FROM A PAID JOB?

YES 1

NO 2 (GO TO H11)

H5. 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/CONTRACT 6

EXPENSE RECEIPT 7

OTHER, SPECIFY 8

H6. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

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

MONTH DAY YEAR

NOT FOUND ON DOCUMENT 99

H7. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

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

NOT FOUND ON DOCUMENT 99

H8. DOES THE PAY STATEMENT REFLECT EARNINGS DURING [APPLICATION MONTH], THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

[APPLICATION MONTH] 1 (GO TO H11)

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS PRIOR TO [APPLICATION MONTH] 5

CURRENT YEAR…………………………………………………… 6

ASK IF H8 DOES NOT = 1

H9. 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 Student Name]]’s eligibility was determined for the school meal program benefits at [Target School].

ABOUT THE SAME 1 (GO TO H11)

LESS 2

MORE 3

H10. What is your best estimate of the amount (you/[person’s name]) received from this paid job during [application month and year]?

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

H11. Did (you/[person’s name]) have any other paid jobs during [application month and year]?

YES 1 (GO TO BOX HB)

NO 2 (GO TO BOX HC)

BOX HB

REPEAT QUESTIONS H1 TO H11 IN A LOOP FOR EVERY JOB UNTIL RESPONSE TO H11 = 2 (NO).

BOX HC

ASK H12-H20 ABOUT ALL OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT PERSON ON CREATED LIST IN BOX HA BEFORE CONTINUING TO ASK THE SAME SERIES FOR THE NEXT ADULT.

ASK H12-H20 ABOUT EVERY OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT PERSON BEFORE CONTINUING TO ASK THE SAME SERIES FOR THE NEXT ADULT.

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 information you have available, to show the amounts (you/[person’s name]) received from these other sources.

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

H12. How much income did (you/[person’s name]) receive from [source in G8], during [application month and year]?

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

OR ADD: Your best estimate is fine.

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

H13. How often did (you/[person’s name]) receive [other income source]?

HOURLY 1

DAILY 2

WEEKLY 3

EVERY 2 WEEKS (BI-WEEKLY) 4

TWICE A MONTH 5

MONTHLY 6

QUARTERLY 7

ANNUALLY 8

OTHER, SPECIFY 9

H14. INTERVIEWER: WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT (RESPONDENT’S/PERSON’S) [INCOME SOURCE PAYMENT?

YES 1

NO 2 (GO TO BOX HD)

RECORD FOR ALL WITH DOCUMENTATION

H15. INTERVIEWER: SPECIFY THE TYPE OF DOCUMENT.

STATEMENT 1

BENEFITS LETTER 2

CHECK STUB 3

INCOME TAX RETURN 4

AWARD LETTER/CONTRACT 5

OTHER, SPECIFY 6

H16. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

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

MONTH DAY YEAR

NOT FOUND ON DOCUMENT 99

H17. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

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

MONTH DAY YEAR

NOT FOUND ON DOCUMENT 99

H18. DOES THE DOCUMENT REFLECT PAYMENT DURING THE APPLICATION MONTH, THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

APPLICATION MONTH 1 (GO TO BOX HD)

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

CURRENT YEAR…………………………………………………………6

ASK IF H18 DOES NOT = 1

H19. Is the amount we just discussed as (your/[person’s name]’s) payment from this 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 Student Name]’’s eligibility was checked for the school meal program benefits at ]Target School].

ABOUT THE SAME 1 (GO TO BOX HD)

LESS 2

MORE 3

H20. What is your best estimate of the amount (you/[person’s name]) received from this [other income source] during [application month and year]?

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

BOX HD

REPEAT THE LOOP OF H12 THROUGH H20 TO ASK ABOUT EACH ADULT PERSON WITH AT LEAST ONE REPORTED SOURCE OF INCOME OR BENEFIT.

SECTION I: TOTAL MONTHLY INCOME

In Section I a total monthly household income is calculated based on previous responses and the respondent is asked to confirm if that total income appears accurate. If not, the respondent is asked to adjust reported income/payment amounts. This approach serves as a check for previous responses of income/benefit payments.

BOX I1

PROGRAMMER NOTE: RUN A CALCULATION OF ALL SOURCES OF REPORTED INCOME/BENEFITS. POST CALCULATED TOTAL TO QUESTION I1. TABLE SHOULD APPEAR FOR INTERVIEWER TO READ FROM.

ASKED TO ALL RESPONDENTS

I1. The computer just added up all the income sources you told me about and the total household income for all household members in [application month and year] (including the income of people no longer here) is [calculated total from all sources]. Does that sound about right?

YES 1 (GO TO I4)

NO 2 (GO TO I2)

ASK IF CALCULATED TOTAL DOES NOT SEEM ACCUARATE.

I2. 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 RESPONDENT EACH INCOME SOURCE AND AMOUNT AND MAKE ADJUSTMENTS WHERE NEEDED. WHEN REVIEW IS COMPLETE, CODE 1 TO CONTINUE.

CONTINUE 1

I3. 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 I2 TO REPEAT REVIEW

OF ALL SOURCES, REPEAT PROCESS UNTIL INCOME IS CORRECTED TO THE RESPONDENT’S SATISFACTION)

ASKED TO ALL RESPONDENTS

I4. Was the [total from all sources listed in section F and G] we just recorded for your household) in [Month] a usual amount, or was it more or less than the average you expect (your/his/her) monthly income to be this school year?

USUAL AMOUNT 1 (GO TO J1)

MORE THAN AVERAGE 2

LESS THAN AVERAGE 3

ASKED IF CALCULATED INCOME IS MORE OR LESS THAN AN AVERAGE MONTH

I5. Since the total amount we just recorded for your household in [Month] is not the usual amount, how much do you expect the usual amount for your monthly household income to be over the school year?

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

SECTION J: DEMOGRAPHIC CHARACTERISTICS

Section J is a series of demographic questions.

The next set of questions will help give us background information on the people completing this survey.

ASK ALL RESPONDENTS

J1. 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

J2. 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

J3. 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?

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 2

J4. Are you American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White?

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

J5. Is English the primary language spoken in this household?

YES 1 (GO TO J7)

NO 2

J6. What is the primary language spoken in the household?

English 1

Spanish 2

Chinese (e.g. Mandarin or Cantonese) 3

French 4

Tagalog 5

Vietnamese 6

Korean 7

Arabic 8

Russian 9

Other (specify) _______________ 10

J7. Are you a United States citizen?

YES 1 (GO TO J9)

NO 2

J8. How long have you lived in the United States?

IF NEEDED: Include the total number of years/months living in the United States.

|___|___| OR |___|___| 1

YEARS MONTHS

OR

SINCE |___|___|___|___| 2

YEAR

OR

MY ENTIRE LIFE 3

The next questions are about [Target Student Name].

J9. Is [Target Student Name] Hispanic or of Latino origin?

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

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 2

J10. Is (she/he) American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White?

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

SECTION K: CLOSE OUT AND FUTURE CONTACT

This final section K closes out the survey and provides for the payment of the respondent. In addition, respondents will be asked if they are willing to be considered for a future interview to discuss their experiences in completing the application for meal benefits for school breakfast and lunch programs. If they are willing, contact information is collected.

K1. INTERVIEWER: DID RESPONDENT PROVIDE SUFFICIENT (AT LEAST ONE SOURCE OF INCOME DOCUMENTATION) INCOME DOCUMENTATION?

YES 1

NO 2

K2. This is the end of the interview. Thank you very much for participating in our study. For (completing this interview/completing this interview and providing your income documentation) you will now receive ($30 for completing the survey/$50 for completing the survey and providing income documentation).

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

K3. We are planning to contact some study participants in the future to learn more about your experiences in completing the application for meal benefits for school breakfast and lunch programs. This would be separate interview by phone. If you are chosen and answer the questions you will receive an additional $20. Would you be interested in being contacted again to participate in this phone interview?

YES 1 (GO TO K4)

NO 2 (GO TO K8)

ASK TO THOSE WILLING TO PROVIDE CONTACT INFORMATION

K4. Let me confirm some contact information for you. I have your phone number as (INSERT PHONE NUMBER). Is that correct?

YES 1 (GO TO K6)

NO 2

K5. Could you please give me a phone number where we can reach you?

ENTER PHONE NUMBER

K6. What is another phone number where we may reach you?

ENTER PHONE NUMBER

NO SECOND NUMBER GIVEN 1

K7. We would also like to have an email address. Do you have an email address where we can contact you? (IF YES:) What is your email address?

YES, 1

NO EMAIL ADDRESS GIVEN 2

K8. Thank you very much for participating in our study. (We may be contacting you again in the future.)