OMB
Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX
The first few questions ask about your store.
Q1. Is this store currently authorized to accept SNAP benefits?
YES
NO
-4 DON’T KNOW
-7 REFUSAL
Q2. Does the owner of this store own and operate any stores at other locations?
YES
NO
-4 DON’T KNOW
-7 REFUSAL
[IF Q2 = 1]
Q3. How many other stores are owned and operated by this store’s owner? Is it…READ LIST.
1 to 3
4 to 6
7 to 9 or
10 or more stores?
-4 DON’T KNOW
-7 REFUSAL
For the remainder of the survey, all questions only concern store number, [INSERT FNS STORE NUMBER].
Q4. How many cash registers/lanes are currently used by this store? DO NOT READ LIST.
1
2
3
4
5
6 OR MORE
-4 DON’T KNOW
-7 REFUSAL
Q5. How does this store connect to the Internet? Do you use a…? READ LIST.
Dial-up telephone line, or
High-speed Internet connection; for example, cable TV modem, fiber optic connection).
THIS STORE DOES NOT HAVE AN INTERNET CONNECTION
OTHER (Please specify): _____________________
-4 DON’T KNOW
-7 REFUSAL
Q6. Is this store also a WIC-authorized vendor? WIC refers to the Women, Infants, and Children Program. READ LIST.
Yes, this store uses paper vouchers
Yes, this store uses Electronic Benefit Transfer system, sometimes called eWIC
No, this store is not WIC-authorized
-4 DON’T KNOW
-7 REFUSAL
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. Would you say…? READ LIST.
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
-4 DON’T KNOW
-7 REFUSAL
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. Would you say…? READ LIST.
None
1 to 24
25 to 49
50 to 99
100 to 499
500 to 999
More than 1,000
-4 DON’T KNOW
-7 REFUSAL
The next set of questions ask about your employees.
Q9. How many full-time employees are currently employed at this store? By full time, we mean working at least 35 hours per week. Count yourself, if appropriate. Would you say… READ LIST.
None
1 or 2
3 or 4
5 to 9
10 to 14
15 to 20
More than 20
-4 DON’T KNOW
-7 REFUSAL
Q10. How many part-time employees are currently employed at this store? By part time, we mean working fewer than 35 hours per week. Count yourself, if appropriate. Would you say… READ LIST.
None
1 or 2
3 or 4
5 to 9
10 to 14
15 to 20
More than 20
-4 DON’T KNOW
-7 REFUSAL
Q11. How many of your full- or part-time employees are primarily responsible for checking out customers? Would you say… READ LIST.
None
1 or 2
3 or 4
5 to 9
10 to 14
15 to 20
More than 20
-4 DON’T KNOW
-7 REFUSAL
[IF Q1 = 2, DISPLAY]
Thank you. You have completed the survey.
[IF Q1 = 2, END SURVEY]
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.
Q12. Is your store’s front-end register system integrated with the EBT payment terminal? Would you say…READ LIST.
Yes, it is integrated, or
No, SNAP transactions must be entered in both the register and payment terminal.
-4 DON’T KNOW
-7 REFUSAL
Q13. Is the payment terminal(s) owned by the store or is it leased? SELECT ALL THAT APPLY.
OWNED
LEASED
OTHER (Please specify): ___________________
-4 DON’T KNOW
-7 REFUSAL
Q14. Who maintains and upgrades your store’s front-end register system? Is it a…? READ LIST. SELECT ONE.
Store employee
Service company or consultant, or does
No one maintain and upgrade the system
OTHER (Please specify): ___________________
-4 DON’T KNOW
-7 REFUSAL
[IF Q14 = 1]
Q14a. What is the job title of the store employee who maintains and upgrades your store’s front-end register system? ___________________
Q15. Does your store’s register system scan barcodes on products during checkout? READ LIST.
Yes, this technology is currently operational,
Yes, you are in the process of purchasing or installing this technology, or
No, this technology is not operational
-4 DON’T KNOW
-7 REFUSAL
[IF Q15 = 1 OR 2]
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? READ LIST.
Yes, this technology is currently operational,
Yes, you are in the process of purchasing or installing this technology, or
No, this technology is not operational
-4 DON’T KNOW
-7 REFUSAL
[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]
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? Would you say…? READ LIST.
Very unlikely
Somewhat unlikely
Neither unlikely nor likely
Somewhat likely
Very likely
-4 DON’T KNOW
-7 REFUSAL
[IF Q15 = 3 OR (Q15 = 1 OR 2 AND Q16 = 3)]
Q18. For the last question, I’m going to read you a list of factors. For each factor, please tell me how important each factor would be in your decision on whether to upgrade or purchase scanning technology that meets the new requirement. I want to know if it would be very unimportant, somewhat unimportant, neitheir unimportant nor important, somewhat important, or very important. The first factor is [XXXXXX] SELECT ONE FOR EACH FACTOR. REPEAT SCALE AFTER AFTER 4 ITEMS, OR AS NECESSARY.
|
Factor |
Very Unimpor-tant |
Somewhat Unimpor-tant |
Neither Unimpor-tant nor Impor-tant |
Some-what Impor-tant |
Very Impor-tant |
-4 DON’T KNOW |
-7 REFUSAL |
a |
Slow or unreliable Internet access |
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b |
Cost to purchase, install, and maintain scanner |
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c |
Lack of technical knowledge |
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d |
Limited checkout stand space |
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e |
Unreliable electrical power causes frequent outages |
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f |
Low SNAP sales volume |
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g |
Possible disruption of store operations during installation |
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h |
Cost to train staff |
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i |
Time to train staff |
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j |
No one available to help with system failures and other troubleshooting |
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k |
Time to evaluate and decide which type of scanner to install |
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l |
Staff have limited English-speaking ability |
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m |
Time to maintain product database |
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Thank you for your time. You have completed the survey. FNS really appreciates your help with this important study. Have a good day.
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 |