OMB
Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX
[DISPLAY]
Please complete this survey even if your business does not currently use scanning technology. Please ask other employees if you do not know the answer to a particular question. For questions that ask for numbers or percentages, your best estimate is acceptable. For purposes of this survey, certain words have particular meanings, so please refer to the definitions provided. Unless otherwise indicated, please choose one answer for each question.
We ask that you please complete the survey within two weeks.
[DISPLAY]
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB 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 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
[DISPLAY]
The first few questions ask about your store.
[SP]
Q1. Is this store currently authorized to accept SNAP benefits?
Yes
No
[SP]
Q2. Does the owner of this store own and operate any stores at other locations?
Yes
No
[IF Q2 = 1]
[SP]
Q3. How many other stores are owned and operated by this store’s owner?
1–3
4–6
7–9
10 or more
[DISPLAY]
For the remainder of the survey, all questions only concern the store location, store number, [INSERT FNS STORE NUMBER].
[SP]
Q4. How many cash registers/lanes are currently used by this store?
1
2
3
4
5
6 or more
[SP]
Q5. How does this store connect to the Internet?
Dial-up telephone line
High-speed Internet connection (e.g., cable TV modem, fiber optic connection)
This store does not have an Internet connection
Other (Please specify): _____________________ [SMALL TEXT BOX]
[SP]
Q6. Is this store also a WIC-authorized vendor? WIC refers to the Women, Infants, and Children Program.
Yes, use paper vouchers
Yes, use Electronic Benefit Transfer system (eWIC)
No
[SP]
Q7. How many unique barcode food products are sold in this store? Do not include products that are sold by weight. Remember that your best estimate is fine.
Fewer than 100
100 to 499
500 to 999
1,000 to 2,999
3,000 to 4,999
5,000 to 9,999
10,000 to 14,999
15,000 to 20,000
More than 20,000
[SP]
Q8. How many other unique food products are sold in this store that do not have a barcode? These items are sometimes sold by weight and can include meat, fruit, vegetables and other items. Your best estimate is fine.
None
1 to 24
25 to 49
50 to 99
100 to 499
500 to 999
More than 1,000
[DISPLAY]
The next set of questions ask about your employees.
[SP]
Q9. How many full-time employees are currently employed at this store (including yourself, if appropriate)? By full time, we mean working at least 35 hours per week.
0
1 or 2
3 or 4
5–9
10–14
15–20
More than 20
[SP]
Q10. How many part-time employees are currently employed at this store (including yourself, if appropriate)? By part time, we mean working fewer than 35 hours per week.
0
1 or 2
3 or 4
5–9
10–14
15–20
More than 20
[SP]
Q11. How many of your full- or part-time employees are primarily responsible for checking out customers?
0
1 or 2
3 or 4
5–9
10–14
15–20
More than 20
[IF Q1 = 2, DISPLAY]
Thank you. You have completed the survey.
[IF Q1 = 2, END SURVEY]
[IF Q1 = 1, DISPLAY]
The next set of questions ask about your store’s front-end register system and use of scanning technologies. By front-end register system, we mean the customer service/checkout lanes featuring a cash register and payment terminal.
[SP]
Q12. Is your store’s front-end register system integrated with the EBT payment terminal?
Yes
No, we must enter SNAP transactions in both the register and payment terminal.
[MP]
Q13. Is the payment terminal(s) owned by the store or is it leased? Select all that apply.
Owned
Leased
Other (Please specify): ___________________ [SMALL TEXT BOX]
[SP]
Q14. Who maintains and upgrades your store’s front-end register system?
Store employee
Service company or consultant
No one
Other (Please specify): ___________________ [SMALL TEXT BOX]
[IF Q14 = 1]
[TEXT]
Q14a. Please provide the job title of the store employee who maintains and upgrades your store’s front-end register system. ___________________ [SMALL TEXT BOX]
[SP]
Q15. Does your store’s register system scan barcodes on products during checkout?
Yes, currently operational
Yes, in the process of purchasing/installing
No
[IF Q15 = 1 OR 2]
[SP]
Q16. Does your store’s register system identify products that are eligible and not eligible for purchase with SNAP benefits (for example, by using a flag or other indicator)?
Yes, it is currently operational
Yes, you are in the process of purchasing/installing
No
[IF Q16 = 1 OR 2, DISPLAY]
Thank you. You have completed the survey.
[IF Q16 = 1 OR 2, END SURVEY]
[IF Q15 = 1 OR 2 AND Q16 = 3]
[SP]
Q17. There is a new law that will require all SNAP-authorized retailers to use scanners at checkout to accept SNAP benefits. In the future, your store may need to upgrade or purchase and maintain new equipment to comply with this law. How likely are you to do this so you can remain a SNAP-authorized retailer?
Very unlikely
Somewhat unlikely
Neither unlikely nor likely
Somewhat likely
Very likely
[IF Q15 = 3 OR (Q15 = 1 OR 2 AND Q16 = 3)]
[SP]
Q18A-E
How important would each of these factors be in your decision on whether to upgrade or purchase scanning technology that meets the new requirement? [RANDOMIZE ORDER OF FACTORS]
Factor |
Very Unimpor-tant |
Somewhat Unimpor-tant |
Neither Unimpor-tant nor Important |
Somewhat Important |
Very Impor-tant |
Slow or unreliable Internet access |
|
|
|
|
|
Cost to purchase, install, and maintain scanner |
|
|
|
|
|
Lack of technical knowledge |
|
|
|
|
|
Limited checkout stand space |
|
|
|
|
|
Unreliable electrical power causes frequent outages |
|
|
|
|
|
[IF Q15 = 3 OR (Q15 = 1 OR 2 AND Q16 = 3)]
[SP]
Q18F-J.
How important would each of these factors be in your decision on whether to upgrade or purchase scanning technology that meets the new requirement? [RANDOMIZE ORDER OF FACTORS]
Factor |
Very Unimpor-tant |
Somewhat Unimpor-tant |
Neither Unimpor-tant nor Important |
Somewhat Important |
Very Impor-tant |
Low SNAP sales volume |
|
|
|
|
|
Possible disruption of store operations during installation |
|
|
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Cost to train staff |
|
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Time to train staff |
|
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|
No one available to help with system failures and other troubleshooting |
|
|
|
|
|
Q18K-M.
How important would each of these factors be in your decision on whether to upgrade or purchase scanning technology that meets the new requirement? [RANDOMIZE ORDER OF FACTORS]
Factor |
Very Unimpor-tant |
Somewhat Unimpor-tant |
Neither Unimpor-tant nor Important |
Somewhat Important |
Very Impor-tant |
Time to evaluate and decide which type of scanner to install |
|
|
|
|
|
Staff have limited English-speaking ability |
|
|
|
|
|
Time to maintain product database |
|
|
|
|
|
[DISPLAY]
Thank you. You have completed the survey.
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Protocols and Guidelines Manual |
Subject | Home Health Care CAHPS Survey |
Author | Centers for Medicare & Medicaid Services |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |