Household Survey Activities

Supporting Statement for OMB Clearance for the Study of Non-Response to the School Meals Application Verification Process

Appendix 12a

Household Survey - English

O MB No.: 0584-xxxx

Expiration Date: xx/xx/xxxx

School Meal Application Study

Household Survey

May 1, 2017

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 2 hours and 45 minutes (2.75 hours), with 45 minutes to complete the survey and 2 hours to gather the income data needed to complete the survey. These time estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

SECTION A: ENROLLMENT STATUS

Reviewer: 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.

Thank-you for taking the time to speak with me today. Participation in this study is voluntary and will not affect any benefits you may be receiving.  All information is private and will not be used in any way that could identify you or your child.  Do you have any questions before we begin?

INTERVIEWER: ANSWER ANY QUESTIONS BEFORE PROCEEDING. IF THE RESPONDENT DOESN’T HAVE ANY QUESTIONS THEN CONTINUE TO A1.

A1. Does [TARGET STUDENT NAME] currently attend [TARGET SCHOOL]?

YES 1 (GO TO A3)

NO 2 (GO TO A2)

DON’T KNOW d (GO TO A5)

STUDENT DECEASED 3 (GO TO A4)

A2. When did she/he stop attending [TARGET SCHOOL]?

PROBE: Was that in the beginning, middle, or the end of the month?

IF BEGINNING OF MONTH, ENTER 01 FOR DAY; IF MIDDLE OF MONTH, ENTER 15 FOR DAY; IF END OF MONTH, ENTER 30 FOR DAY.

|___|___| / |___|___| / |___|___| (GO TO BOX AA)

MONTH DAY YEAR

BOX AA

IF [TARGET STUDENT NAME] LEFT [TARGET SCHOOL] BEFORE 2017-2018 SCHOOL YEAR, GO TO A5.

IF [TARGET STUDENT NAME] ATTENDED [TARGET SCHOOL] AT ANY POINT DURING 2017-2018 SCHOOL YEAR, GO TO A3.

A3. 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 OF MONTH, ENTER 01 FOR DAY; IF MIDDLE OF MONTH, ENTER 15 FOR DAY; IF END OF MONTH, ENTER 30 FOR DAY.

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

MONTH DAY YEAR

FIRST DAY OF SCHOOL 1 (GO TO SECTION B)

NEVER ATTENDED THIS YEAR 2 (GO TO A6)

A4. I am very sorry to hear about your loss. We will not do an interview. Thank you for your time. INTERVIEWER TERMINATE INTERVIEW.

A5. We are only interested in talking to parents or guardians of the student who attended [TARGET SCHOOL] this school year. We do not need to conduct an interview with you. Thank you for your time. INTERVIEWER TERMINATE INTERVIEW.

SECTION B: PARTICIPATION IN SCHOOL BREAKFAST AND LUNCH PROGRAMS

Reviewer: Section B asks about the student’s participation in the school breakfast and/or lunch program during the most recent 5-day school week.

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 on any day during the last full week of school. I am referring to the meals provided under the National School Lunch Program/National School Breakfast 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.

PROBE: By school breakfast, I mean a complete breakfast provided by the school.

PROBE: By school lunch, I mean a complete meal such as a fruit or vegetable, sandwich and milk, or a hot meal and milk for free or at a set, fixed price.

CODE WITHOUT ASKING IF KNOWN:

B1. 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

B2. 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 BA

IF [TARGET SCHOOL] HAS A SCHOOL BREAKFAST PROGRAM, ASK B3; ELSE GO TO B4.

B3. How many days did he/she eat a school breakfast?

|___|

NUMBER OF DAYS ATE SCHOOL BREAKFASTS (GO TO B4)

DON’T KNOW/DON’T REMEMBER d (GO TO B3a)

NONE, DID NOT EAT BREAKFAST/SCHOOL BREAKFAST… 0 (GO TO B4)

If B3 = D

B3a. Did he/she eat a school breakfast at least once?

YES 1

NO 2

DON’T KNOW/DON’T REMEMBER d

BOX BB

IF B3 = 0, OR B3 = D AND B3A = 2 OR D, THEN SKIP C1A THROUGH C1C.

B4. How many days did he/she eat a school lunch?

|___|

NUMBER OF DAYS ATE SCHOOL LUNCHES (GO TO BOX C1A)

DON’T KNOW/DON’T REMEMBER d (GO TO B4a)

NONE, DID NOT EAT LUNCH/SCHOOL LUNCH 0 (GO TO BOX C1A)

If B4 = D

B4a. Did he/she eat a school lunch at least once?

YES 1

NO 2

DON’T KNOW/DON’T REMEMBER d

BOX BC
IF B4 = 0, OR B4 = D AND B4A = 2 OR D, SKIP C1D THROUGH C1F.

SECTION C: PERCEPTIONS OF SCHOOL MEALS

Reviewer: Section C asks the parent/guardian about the student’s perception of school meals, the parent/guardian’s perception of the school meals, and the parent/guardian’s perception of the fairness of the school meals application process.

The next questions are about [TARGET STUDENT NAME]’s satisfaction with school breakfast meals at [TARGET SCHOOL].

HAND SHOWCARD #1 TO RESPONDENT

	Regarding the school breakfast meals at [TARGET SCHOOL], how satisfied 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 Don’t know d
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 Don’t know d
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 Don’t know d

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 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 Don’t know d
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 Don’t know d
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 Don’t know d

The next questions are about your satisfaction with school breakfast meals at [TARGET SCHOOL].

HAND SHOWCARD #2 TO RESPONDENT

	Regarding the school breakfast meals at [TARGET SCHOOL], how satisfied are/were you with …?	RESPONSE
C2a.	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 Don’t know……………………d

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
C2b.	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 Don’t know……………………d

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

YES 1

NO 2

The next question is about your satisfaction with the free and reduced price school meals application process.

HAND SHOWCARD #3 TO RESPONDENT

	Regarding the process for applying for free and reduced price school meals …	RESPONSE
C4.	Do you find the process…?	Very fair 1 Somewhat fair 2 Somewhat unfair 3 Very unfair 4 Don’t know d

SECTION D: PERCEPTIONS OF VERIFICATION PROCESS

Section D asks about the parent/guardian's perceptions of the verification process. It includes questions about the difficulty of the process, and asks respondents who failed to complete the verification request about why they did not complete.

INTRO TO SECTION: Next, I would like to ask questions about your experience with the Free and Reduced Price School Meals Verification process.

ASK ALL HOUSEHOLDS

D1. Did the school district contact you to check the accuracy of your application during this school year?

YES 1 (GO TO D3)

NO 2 (GO TO D2)

DON’T KNOW d (GO TO D2)

REFUSED r (GO TO D2)

If D1 ≠ 1

D2. Federal rules require school districts to randomly check a small number of applications each year to make sure they are accurate. Our records show that your application was selected back in Fall 2017. The school district would have contacted you and asked you to provide proof of your income to verify your application.

Were you contacted about that in the Fall of 2017?

YES 1 (GO TO D3)

NO 2 (GO TO D11)

DON’T KNOW d (GO TO D11)

REFUSED r (GO TO D11)

BOX DA

IF D1 = 1 or D2 = 1, GO TO D3. ELSE, GO TO D11.

If D1 = 1 or D2 = 1

D3. When you were contacted did you receive…?

SELECT ALL THAT APPLY

YES NO DK REF

a. A letter 1 2 d r

b. A phone call 1 2 d r

c. An email 1 2 d r

d. A text 1 2 d r

If D3 a, c, d = 1

D3_a. Was the (letter/email/text) in your preferred language?

YES 1

NO 2

DON’T KNOW d

REFUSED r

ASK NONRESPONDING HOUSEHOLDS (D4-D13)

IF RESPONDING HOUSEHOLD WITH NO CHANGES, SKIP TO D11.

If D1 or D2 = 1

D4. Did you try to complete the request?

YES 1 (GO TO D5)

NO 2 (GO TO D5)

DON’T KNOW d (GO TO D5)

REFUSED r (GO TO D5)

D5. How clear were the instructions in the letter and form that came with the request? Would you say they were…?

HAND SHOWCARD #4 TO RESPONDENT

Very clear 1

Somewhat clear 2

Neither clear nor unclear 3

Somewhat unclear 4

Very unclear 5

Don’t know/don’t remember d

D6. How easy would it have been to complete the request on time? Would it have been…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

Don’t know/don’t remember d

D7. How easy would it have been to provide the requested information such as pay stubs, letters, or copies of pay checks? Would it have been…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

Don’t know/don’t remember d

The next questions are about how easy it would have been for you to provide proof of your income.

HAND SHOWCARD #6 TO RESPONDENT

	How easy would it have been to provide proof of…	RESPONSE
D8a	Income from your job? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA
D8b	Income from child support? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA
D8c	Income from unemployment, disability, or worker’s comp? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA
D8d	Income from Social Security, pensions, or retirement? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA
D8e	Income from welfare payments? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA
D8f	Other income, such as rental income? Would it have been…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable NA

If all answers for D8a through D8f = NA

D9. How easy would it have been to provide a brief note explaining how you provide food, clothing, and housing for your household? Would it have been…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

D10. What are the reasons why you did not complete the request?

REASON

DON’T KNOW d

REFUSED r

D10a. What would you say is the most important reason why you did not complete the request?

(STRING 250)

REASON

DON’T KNOW d

REFUSED r

ASK ALL HOUSEHOLDS D11 THROUGH D13

Now we are going to ask you a few questions about your contact information.

D11. How many times have you moved since [DISTRICT FIRST DAY OF SCHOOL]?

| | |

(0-20) GO TO D11b

DIDN’T MOVE SINCE BEGINNING OF SCHOOL YEAR 0 GO TO D12

DON’T KNOW d GO TO D11a

REFUSED r GO TO D11a

D11=d OR r

D11a. I just need a range. Would you say you moved…

CODE ONE ONLY

1-2 times, 1 GO TO D11b

3-5 times, 2 GO TO D11b

6-9 times, 3 GO TO D11b

Or 10 or more times? 4 GO TO D11b

VOLUNTEERED, DID NOT MOVE 0 GO TO D12

DON’T KNOW d GO TO D12

REFUSED r GO TO D12

D11b. In what month and year was your most recent move?

IF RESPONDENT SAYS DATE BEFORE AUGUST 2017 SAY: Remember I’m only asking about any moves since [DISTRICT FIRST DAY OF SCHOOL]. Did you move since [DISTRICT FIRST DAY OF SCHOOL]?

IF DATE NOT KNOWN, ENTER 00

|__|__| MONTH |__|__| DAY |__|__|__|__| YEAR

DON’T KNOW d

REFUSED r

D12. Do you currently own an active cell phone?

YES 1 GO TO D12B

NO 2

DON’T KNOW d

REFUSED r

D12a. Have you owned a cell phone at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO ……..2 GO TO D13

DON’T KNOW d GO TO D13

REFUSED r GO TO D13

ASK IF D12 =1 OR D12a = 1

D12b. Was your cell phone deactivated at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO 2

DON’T KNOW d

REFUSED r

ASK IF D12 =1 OR D12a = 1

D12c. Has your cell phone number changed since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO 2

DON’T KNOW d

REFUSED r

ASK IF D12=1

D12d. How many times has your cell phone number changed since [DISTRICT FIRST DAY OF SCHOOL]?

|__|__| TIMES

DON’T KNOW d

REFUSED r

D13. Do you currently have a landline? By “landline” I mean a traditional telephone line in your home that is separate from your cell phone.

YES 1 GO TO D13B

NO 2 GO TO D13a

DON’T KNOW d

REFUSED r

D13a. Have you had a landline at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO 2 GO TO D14

DON’T KNOW d GO TO D14

REFUSED r GO TO D14

ASK IF D13 =1 OR D13a = 1

D13b. Was your landline deactivated at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO 2

DON’T KNOW d

REFUSED r

ASK IF D13 =1 OR D13a = 1

D13c. Has your landline number changed since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1

NO 2

DON’T KNOW d

REFUSED r

ASK IF D13c=1

D13d. How many times has your landline number changed since [DISTRICT FIRST DAY OF SCHOOL]?

|__|__| TIMES

DON’T KNOW d

REFUSED r

ASK RESPONDING HOUSEHOLDS (D14-D17), ELSE GO TO E1

If D1 or D2 = 1

D14. How clear were the instructions in the letter and form that came with the request? Would you say they were…?

HAND SHOWCARD #4 TO RESPONDENT

Very clear 1

Somewhat clear 2

Neither clear nor unclear 3

Somewhat unclear 4

Very unclear 5

D15. How easy was it for you to complete the request on time? Was it…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

D16. How easy was it for you to provide information such as pay stubs, letters, or copies of checks that proved your child was eligible? Was it…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

The next questions are about how easy it was to provide proof of your income.

HAND SHOWCARD #6 TO RESPONDENT

	How easy was it to provide proof of…?	RESPONSE
D17a	Income from your job? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA
D17b	Income from child support? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA
D17c	Income from unemployment, disability, or worker’s comp? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA
D17d	Income from Social Security, pensions, or retirement? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA
D17e	Income from welfare payments? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA
D17f	Other income, such as rental income? Was it…?	Very easy 1 Somewhat easy 2 Neither easy nor difficult 3 Somewhat difficult 4 Very difficult 5 Not applicable………………NA

If all answers for D17a through D17f = NA

D18. How easy was it to provide a brief note explaining how you provide food, clothing, and housing for your household? Was it…?

HAND SHOWCARD #5 TO RESPONDENT

Very easy 1

Somewhat easy 2

Neither easy nor difficult 3

Somewhat difficult 4

Very difficult 5

D19. What are the most important reasons why you completed the request that came from the school?

(STRING 250)

REASON

DON’T KNOW d

REFUSED r

D20. How much time did you spend completing the request? Did it take…?

Less than 30 minutes 1

30 minutes to an hour 2

More than one hour but less than four hours 3

Four hours or more 4

Don’t know/don’t remember d

SECTION E: HOUSEHOLD COMPOSITION

Section E 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, age, grade level for children and occupation for adults. In this section, we also ask if anyone else lived in the household in October 2017.

INTRO TO SECTION: Next, I would like to ask questions about [TARGET STUDENT NAME].

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

SIBLING (BROTHER OR SISTER) 5

NEPHEW OR NIECE 6

COUSIN 7

GRANDCHILD 8

OTHER RELATIVE 9

NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 10

OTHER (SPECIFY) 11

E2. What is [TARGET STUDENT NAME]’s date of birth?

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

MONTH DAY YEAR

E3. Did [TARGET STUDENT NAME] live with you in October 2017?

YES 1

NO 2

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

ASK EVERYONE

E4. I have your legal name recorded as [PARENT/GUARDIAN NAME]. Is this correct?

INTERVIEWER: SPELLING OF RECORDED NAME SHOULD BE CONFIRMED.

YES 1 (GO TO E6)

NO 2 (GO TO E5)

E5. May I please have the correct spelling of your legal name?

FIRST NAME LAST NAME

E6. 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 E11)

E7. CODE IF KNOWN OR ASK: Does [TARGET STUDENT NAME] live with you now?

YES 1

NO 2

E8. Please tell me the first name of everyone who lives here with you.

FILL IN NAME OF RESPONDENT IN POSITION #1.

FILL NAME OF TARGET CHILD IN POSITION #2.

INTERVIEWER: DO NOT ASK ABOUT TARGET STUDENT.

PROBE: Who else lives with you?

________________________ RESPONDENT (NAME # 1)	________________________ NAME # 6	____________________ NAME # 11
______________________ TARGET STUDENT (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 EA

PROGRAMMER NOTE: ALLOW AS MANY RECORDS AS NEEDED TO LIST ENTIRE HOUSEHOLD MEMBERSHIP. QUESTIONS E9-15 WILL BE ASKED OF EVERY MEMBER OF THE HOUSEHOLD, EXCEPT [TARGET STUDENT NAME].

SKIP QUESTION E9 WHEN ASKING ABOUT THE RESPONDENT.

NOTE TO READER: FOR DEMONSTRATION PURPOSES QUESTIONS E9 THROUGH E14 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 E9 THROUGH E14 FOR EACH PERSON.

	____________________ RESPONDENT	____________________ NAME #2	____________________ NAME #3
E9. 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
If asking about the respondent fill “your”. E10. What is (her/his)(your) date of birth?	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO E12 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO E12 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO E12 Age will be calculated
If asking about the respondent fill “are you”. E11. How old (is he/she)/(are you)?	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|
IF AGE IS AGE 5-18, ASK E12; OTHERWISE, SKIP TO E14. If asking about the respondent fill “are you”. If asking about another HH member fill “is [NAME]”. E12. (Is [NAME]/Are you) currently attending school?	YES 1 NO 2 (GO TO E14)	YES 1 NO 2 (GO TO E14)	YES 1 NO 2 (GO TO E14)
If asking about the respondent fill “are you”. If asking about another HH member fill “is she/he”. E13. What grade (is she/he)/(are you) in?	|___|___| GRADE OR PRESCHOOL 1 KINDERGARTEN 2 GRADES 1-2 3 GRADES 3-5 4 GRADES 6-8 5 GRADES 9-12 6 UNGRADED 7	|___|___| GRADE OR PRESCHOOL 1 KINDERGARTEN 2 GRADES 1-2 3 GRADES 3-5 4 GRADES 6-8 5 GRADES 9-12 6 UNGRADED 7	|___|___| GRADE OR PRESCHOOL 1 KINDERGARTEN 2 GRADES 1-2 3 GRADES 3-5 4 GRADES 6-8 5 GRADES 9-12 6 UNGRADED 7
E14. Did [NAME] live with you in October 2017?		YES 1 NO 2	YES 1 NO 2
	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)

BOX EB

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

ASK EVERYONE

E15. 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? Do not include temporary visitors.

IF NEEDED, ADD: By temporary visitors I mean anyone who stays here less than half the time.

YES 1

NO 2 (RETURN TO E8 AND

ADD NAMES TO THE

HOUSEHOLD ROSTER)

E16. Did anyone (else) live with you in this household in October 2017 that does not live with you now?

IF NEEDED, ADD: This is the month when you were asked to report your income when [TARGET STUDENT NAME]’s eligibility was checked for the school meals program benefits at [TARGET SCHOOL].

IF NEEDED, ADD: Remember not to include anyone who stayed here less than half the nights in October 2017.

YES 1 (GO TO E17)

NO 2 (GO TO E19)

E17. How many other people lived with you in October 2017 that do not live with you now?

|___|

ADDITIONAL HOUSEHOLD MEMBERS

E18. Please tell me the first name(s) of the other (person/people) that lived with you in October 2017 but no longer live here with you now.

______________________________

NAME OF OTHER PERSON # 1

______________________________

NAME OF OTHER PERSON # 2

______________________________

NAME OF OTHER PERSON # 3

BOX EC

FOR EACH ADDITIONAL HOUSEHOLD PERSON RECORDED IN E18, LOOP BACK TO E8 AND ASK E9 TO E14 FOR EACH NAME.

ASK E19 TO E22 FOR EACH PERSON LISTED ON ROSTER UNDER AGE 18 AND NOT A FOSTER CHILD.

E19. In October 2017, did you (or your spouse/partner) pay any household expenses or provide any financial support for [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.

E20. 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 (GO TO BOX ED)

NO 2 (RETURN TO E8)

BOX ED

CREATE A LIST OF ALL HOUSEHOLD MEMBERS AGES 16 AND UP EXCLUDING THE RESPONDENT AND THE RESPONDENT’S SPOUSE OR PARTNER. USE THIS LIST TO ASK E21 AND E22.

REPEAT E21 AND E22 UNTIL EACH ADULT (16+) HOUSEHOLD MEMBER ON THE CREATED LIST IS ASKED ABOUT EACH CHILD UNDER THE AGE OF 18.

E21. In October 2017, did [NAME OF EACH HOUSEHOLD MEMBER ON THE CREATED LIST (REFERENCED IN BOX ABOVE)] pay any household expenses or provide any financial support for [NAME OF CHILD UNDER 18 YEARS]?

YES 1

NO 2

E22. In October 2017, 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

E23. ASK E23 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 F: CATEGORICAL ELIGIBILITY

Section F asks a series of questions to determine if the target student was categorically eligible for free meals.

INTRO TO SECTION: Next, I would like to ask questions about benefits your household may receive through government programs like the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF). 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.

SNAP BENEFITS

Let’s discuss any [SNAP/STATE NAME FOR SNAP] benefits your household may receive. Do not include [SNAP/STATE NAME FOR SNAP] benefits received by another household member with their own [SNAP/STATE NAME FOR SNAP] case number that does not include you, your spouse, and/or your child/children.

F1. In October 2017, did you, your spouse, and/or child/children receive SNAP benefits (formerly known as Food Stamps), or [STATE NAME FOR SNAP] benefits?

YES 1 (GO TO F3)

NO 2 (GO TO F2)

F2. Did you, your spouse, and/or child/children receive SNAP benefits or [STATE NAME FOR SNAP] benefits at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1 (GO TO F3)

NO 2 (GO TO F7)

F3. We need to verify that you and your child/children/you and your spouse and child/children received [SNAP/STATE NAME FOR SNAP] benefits since [DISTRICT FIRST DAY OF SCHOOL]. We can get that from your [SNAP/STATE NAME FOR SNAP] EBT card, award statement, or notification of payment. Do you have a [SNAP/STATE NAME FOR SNAP] EBT card, award statement, or notification of payment you can show me?

YES 1 (GO TO F4)

NO 2 (GO TO F7)

F4. INTERVIEWER: WHAT KIND OF DOCUMENTATION DID THE RESPONDENT PROVIDE?

SNAP EBT CARD 1

AWARD STATEMENT 2

NOTIFICATION OF PAYMENT 3

OTHER (SPECIFY) 4

NONE 5

F4a. INTERVIEWER: IF THE RESPONDENT PROVIDES DOCUMENTATION THAT DOES NOT COVER THE 2017-2018 SCHOOL YEAR, PLEASE RECORD THE DATES THE DOCUMENTATION COVERS.

DATE (STRING 50)

F5. Does anyone else in your household receive [SNAP/state name for SNAP] under a different case number?

YES 1 (GO TO F6)

NO 2 (GO TO F7)

F6. Do you share housing, income, or food expenses with this person?

YES 1 (GO TO F7)

NO 2 (GO TO F7)

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.

F7. In October 2017, did you, your spouse, and/or child/children receive TANF, also known as cash welfare, or [STATE NAME FOR TANF]?

YES 1 (GO TO F9)

NO 2 (GO TO F8)

F8. Did you, your spouse, and/or child/children receive [TANF/STATE NAME FOR TANF] benefits at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1 (GO TO F9)

NO 2 (GO TO F13)

F9. We need to verify that you and your child/children/you and your spouse and child/children received [TANF/STATE NAME FOR TANF] benefits since [DISTRICT FIRST DAY OF SCHOOL]. We can get that from your [TANF/STATE NAME FOR TANF] EBT card, award statement, or notification of payment. Do you have a [TANF/STATE NAME FOR TANF] EBT card, award statement, or notification of payment you can show me?

YES 1 (GO TO F10)

NO 2 (GO TO F13)

F10. INTERVIEWER: WHAT KIND OF DOCUMENTATION DID THE RESPONDENT PROVIDE?

[TANF/STATE NAME FOR TANF] EBT CARD 1

AWARD STATEMENT 2

NOTIFICATION OF PAYMENT 3

OTHER (SPECIFY) 4

NONE 5

F10a. INTERVIEWER: IF THE RESPONDENT PROVIDES DOCUMENTATION THAT DOES NOT COVER THE 2017-2018 SCHOOL YEAR, PLEASE RECORD THE DATES THE DOCUMENTATION COVERS.

DATE (STRING 50)

F11. Does anyone else in your household receive [TANF/STATE NAME FOR TANF] under a different case number?

YES 1 (GO TO F12)

NO 2 (GO TO F13)

F12. Do you share housing, income, or expenses with this person?

YES 1 (GO TO F13)

NO 2 (GO TO F13)

OTHER BENEFITS

F13. In October 2017, 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 (GO TO F15)

NO 2 (GO TO F14)

F14. Did you, your spouse, and/or child/children receive FDPIR benefits at any point since [DISTRICT FIRST DAY OF SCHOOL]?

YES 1 (GO TO F15)

NO 2 (GO TO G1)

F15. We need to verify that you and your child/children/you and your spouse and child/children received FDPIR benefits since [DISTRICT FIRST DAY OF SCHOOL]. We can get that from your letter that says you were approved for FDPIR benefits. Do you have a FDPIR award letter you can show me?

YES 1 (GO TO F16)

NO 2 (GO TO G1)

F16. INTERVIEWER: WHAT KIND OF DOCUMENTATION DID THE RESPONDENT PROVIDE?

AWARD STATEMENT 1

OTHER (SPECIFY) 2

NONE 3

F16a. INTERVIEWER: IF THE RESPONDENT PROVIDES DOCUMENTATION THAT DOES NOT COVER THE 2017-2018 SCHOOL YEAR, PLEASE RECORD THE DATES THE DOCUMENTATION COVERS.

DATE (STRING 50)

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-G5 OF EACH CHILD UNDER THE AGE OF 18 WHO HAD FINANCIAL SUPPORT FROM THE PARENT OR GUARDIAN.

G1. In October 2017, did ([TARGET STUDENT NAME]/[CHILD’S NAME]) have any income from Social Security (including Disability Payments or Survivors Benefits), 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 (GO TO G2)

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?

INTERVIEWER: IF THE RESPONDENT MENTIONS CHILD SUPPORT, SAY: The government considers child support to be income for the adult who cares for the child, rather than income for the child itself. I will ask you about any child support in a moment when I ask about income that you collect yourself.

SOCIAL SECURITY OR DISABILITY SURVIVORS BENEFITS 1 (ASK G3)

PERSONS OUTSIDE THE HOUSEHOLD (E.G., FRIEND OR EXTEND FAMILY MEMBER REGULARLY GIVES CHILD SPENDING MONEY) 2 (ASK G4)

OTHER (E.G., INCOME FROM A PRIVATE PENSION FUND, ANNUITY, OR TRUST- PLEASE SPECIFY) 3 (ASK G5)

G2=1

G3. How much is received monthly in Social Security benefits or disability survivors benefits?

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

G2=2

G4. How much is received monthly from persons outside the household?

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

G2=3

G5. How much is received monthly from the other sources?

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

REPEAT G1 TO G5 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 16 OR OLDER AND REPORTED TO HAVE FINANCIAL RESPONSIBILITY FOR CHILDREN IN THE HOUSEHOLD.

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 as we work through the next set of questions.

ASK G6 FOR EACH ADULT (16+) CREATED IN BOX GB.

IF RESPONDENT FILL “YOU”

G6. Let’s review each source of income. Did [you](he/she) receive [SOURCE 1] in October 2017?

YES 1

NO 2

INTERVIEWER: USE THE SHOWCARD TO GO THROUGH EACH INCOME SOURCE OPTION. ASK ABOUT EACH SOURCE OF INCOME ON THE CARD. RECORD EACH SOURCE TYPE FOR HOUSEHOLD INCOME AND BENEFIT PAYMENT ON 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. Do not include infrequent earnings, such as income from occasional baby-sitting or mowing lawns. 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 Survivors 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. Survivors 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 Subsistence 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, but exclude money used for tuition, books, and fees, including 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 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/State name for TANF or SNAP/state name for 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? 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.

IF RESPONDENT REPORTS NO INCOME FROM PAID WORK AT G6 THEN ASK G7-G8

G7. Have you worked for pay at any point since [DISTRICT FIRST DAY OF SCHOOL]? Please include regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, “informal” work, or any other types of work you have done.

YES 1

NO 2

DON’T KNOW d

REFUSED r

G8. In what month and year did you last work for pay? Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, “informal” work, or any other types of work you have done.

|     |     |   |     |     |     |    |

MONTH       YEAR

(1-12)      (1930-2018)

NEVER WORKED FOR PAY 1

DON’T KNOW d

REFUSED r

SECTION H: INCOME AND EARNING AMOUNTS

Section H records and documents all income sources in October 2017 for all incomes and benefits reported in Section G.

BOX HA

CREATE LIST OF ALL RESPONDENTS AGE 16 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, pay stubs, or last year’s income tax return for earnings from jobs, last year’s W-2 forms, 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 (16+) 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 in October 2017. Let’s work together, using the documentation you have available, to document the total pay received for each paid job in October 2017.

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 each paid job in October 2017. The amount I need is the gross income, before taxes and other deductions which was (your/[PERSON’S NAME]’s) total pay, not the amount that was brought home.

Please include salary, wages, tips, commissions, cash bonuses, 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 October 2017.

How much did (you/[PERSON’S NAME]) earn from a paid job in October 2017?

IF APPROPRIATE, ADD: We can probably get that amount from the earnings statement.

IF NEEDED, ADD: Can you show me an earnings statement from October 2017? An earnings statement shows your gross income, which is your income before taxes and other deductions are taken out. It will also show your income after taxes and deductions are taken out, which is also known as your take home pay. You may be able to access your earnings statement online. A pay stub would be fine.

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

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

H2. How often (are/were) 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)

DON’T KNOW d (GO TO H3)

ASK IF H2 = DON’T KNOW

H3. We need to record how many times (you were/[person’s name was]) paid in October 2017. 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

BANK STATEMENT 8

BENEFITS LETTER 9

CHECK STUB 10

W-2 FORM 11

OTHER (SPECIFY) 12

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 IN OCTOBER 2017, THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

OCTOBER 2017 1 (GO TO H11)

CURRENT MONTH 2

BETWEEN OCTOBER 2017 AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO OCTOBER 2017 4

MORE THAN 3 MONTHS PRIOR TO OCTOBER 2017 5

CURRENT YEAR (ENTIRE YEAR OF 2017) 6

ASK IF H8 DOES NOT = 1

H9. Is the income amount on this pay statement about the same as, less than, or more than (your/[PERSON’S NAME]) income from this job in October 2017?

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 in October 2017?

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

H11. Did (you/[PERSON’S NAME]) have any other paid jobs in October 2017?

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 (16+) ON CREATED LIST IN BOX HA 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 in October 2017. 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 G6], in October 2017?

IF APPROPRIATE, ADD: We can probably get this this amount from the payment statement. Do you have a benefits statement from October 2017?

OR ADD: Your best estimate is fine.

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

H13. How often did you receive (your/[PERSON’S NAME]’s) [other income source] in October 2017?

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.

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

BANK STATEMENT 8

BENEFITS LETTER 9

OTHER (SPECIFY) 10

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 FROM OCTOBER 2017, THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

OCTOBER 2017 1 (GO TO BOX HD)

CURRENT MONTH 2

BETWEEN OCTOBER 2017 AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO OCTOBER 2017 4

MORE THAN 3 MONTHS SINCE OCTOBER 2017 5

CURRENT YEAR (ENTIRE YEAR OF 2017) 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 October 2017?

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 [other income source] in October 2017?

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

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.

ASK EVERYONE

I1. The computer just added up all the income sources you told me about and the gross total household income for all household members in October 2017 (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 I2 and I3 IF CALCULATED TOTAL DOES NOT SEEM ACCURATE.

I2. Since you believe that the gross total household income 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 gross 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)

ASK EVERYONE

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) gross monthly income to be this school year?

USUAL AMOUNT 1 (GO TO J1)

MORE THAN AVERAGE 2 (GO TO I4a)

LESS THAN AVERAGE 3 (GO TO I4b)

IF I4 = 2

I4a. Why do you consider this amount to be more than average?

WORKED MORE HOURS AT USUAL JOB(S) 1 (GO TO I5)

RECEIVED A RAISE AT USUAL JOB(S) 2 (GO TO I5)

WORKED AT NEW JOB IN ADDITION TO USUAL JOB(S) 3 (GO TO I5)

LEFT USUAL JOB(S) FOR A HIGHER PAYING JOB 4 (GO TO I5)

RECEIVED MORE BENEFITS/ASSISTANCE THAN USUAL 5 (GO TO I5)

DON’T KNOW 6 (GO TO I5)

REFUSED 7 (GO TO I5)

OTHER (SPECIFY) 8 (GO TO I5)

IF I4 = 3

I4b. Why do you consider this amount to be less than average?

NO LONGER WORKING AT USUAL JOB(S) 1 (GO TO I5)

WORKED FEWER HOURS AT USUAL JOB(S) 2 (GO TO I5)

RECEIVED LESS PAY AT USUAL JOB(S) 3 (GO TO I5)

RECEIVED LESS BENEFITS/ASSISTANCE THAN USUAL 4 (GO TO I5)

DON’T KNOW 5 (GO TO I5)

REFUSED 6 (GO TO I5)

OTHER (SPECIFY) 7 (GO TO I5)

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 gross monthly household income to be over the 2017-18 school year?

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

SECTION J: DEMOGRAPHIC CHARACTERISTICS

Section J is a series of demographic questions about the respondent and target student.

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

ASK EVERYONE

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?

CODE 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

REFUSED r

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?

Spanish 2

Chinese (e.g. Mandarin or Cantonese) 3

French 4

Tagalog 5

Vietnamese 6

Korean 7

Arabic 8

Russian 9

OTHER (SPECIFY) 10

The next questions are about [TARGET STUDENT NAME].

J7. 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

J8. Is (she/he) American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White?

CODE 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

REFUSED r

SECTION K: CONCLUSION

Section K concludes the household interview, thanks the respondent for participating, and provides guidance for distributing a gift card.

Those are all the questions I have for you. Before I go, I’d like to give you this gift card to thank you for participating in this important study. Please sign here to acknowledge that you’ve completed the survey and received your gift. Thank you.

INTERVIEWER: HAVE THE RESPONDENT SIGN THE RESPONDENT PAYMENT LOG

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