Appendix 28 Pretest Memo

28. Pretest Memo.pdf

Study of Non-Response to the School Meals Application Verification Process

Appendix 28 Pretest Memo

OMB: 0584-0638

Document [pdf]

Download: pdf | pdf

Supporting Statement for OMB Clearance for the Study of Non-Response to the
School Meals Application Verification Process
Appendix 28
Pretest Memo

MEMORANDUM

P.O. Box 2393
Princeton, NJ 08543-2393
Telephone (609) 799-3535
Fax (609) 799-0005
www.mathematica-mpr.com

TO:

Courtney Paolicelli

FROM:

Meg Bishop, Cheryl DeSaw, Bryce Onaran,
Rachel Sutton-Heisey, and Eric Zeidman

SUBJECT:

Pretest Summary for the Study of Non-Response to the
School Meals Application Verification Process

DATE: 3/23/2017

Introduction

As part of the Study of Non-Response to the School Meals Application Verification Process,
Mathematica Policy Research will conduct several data collection efforts. To identify typical
instrumentation problems, measure the response burden, and confirm there are no unforeseen
difficulties in administration, Mathematica pretested two survey instruments and two data
request forms. In the sections that follow, this memorandum briefly describes the instruments
followed by the district and household pretest findings.
1.

Verification Data Request

The Verification Data Request will collect data on household characteristics and verification
results for all households selected for verification. Types of data collected will include
background information on households selected for verification, information related to the
original household application for school meal benefits, information related to the verification
process, and parent or guardian contact information. Recruiters from Mathematica will
encourage SFA directors to submit their data via a secure file transfer site. However, if
respondents require assistance in abstracting the requested data from applications then
Mathematica will send trained data collectors to the district to manually collect the information.
We will use the data gathered from these requests to draw a random sample of households that
we will approach to complete the household survey. Mathematica will send Verification Data
Requests to the 20 participating School Food Authority (SFA) directors or their representatives
in fall 2017.
2.

Household survey

The in-home household survey will collect detailed information on household structure,
sources of income, employment history of adult members of the household, and, for each
household member, monthly income by source. The survey will also collect information about
perceptions of the application and verification process, frequency with which students in the
household eat schools meals, and perceptions of the school lunch program. We will administer
this instrument to two key groups of households randomly selected from the verification data
provided by the district in fall 2017: 1) households that did not respond to verification requests,
An Affirmative Action/Equal Opportunity Employer

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 2
and (2) responding households with no changes in benefits. The household survey will be
administered (n=1480) in the winter and spring of 2018 and will be available in both English and
Spanish.
3.

District interview

The purpose of these interviews is to learn more about the district’s verification for cause
processes, and to complement the data collected in the Verification Data Request. During these
interviews, SFA directors will also provide information about the following: how SFAs notify
households that their application has been selected for verification, how and when districts select
applications for cause, whether SFA directors use a formal or informal set of criteria to identify
questionable applications, whether and how direct verification occurs among applications that
have been selected for cause, and procedures for notifying households about their applications
being verified for cause. We will administer the district interview by phone to SFA directors or
their representatives in January and February 2018, to the 20 participating districts.
4.

Reapplication Data Request

The Reapplication Data Request will collect data on reapplication information such as
certification status resulting from reapplication, direct certification information, and enrollment
status information. Mathematica will request that districts upload these data to the secure file
transfer site by the end of March 2018. We will send the Reapplication Data Request to the SFA
directors or representatives in each of the 20 participating districts in March 2018.
II.

District pretest

District recruitment

Mathematica began recruiting SFAs for the pretest in late January 2017. We chose five
districts that met the sampling criteria of the study 1. We also intentionally selected districts
located far from districts likely to be part of the final sample, as the distant geographic locations
of these pretest districts would make them unlikely to be included in the final sample for
logistical reasons.
After we selected five districts to participate, the Food and Nutrition Service (FNS) asked
the Western and Southeastern Regional Offices to email the State Child Nutrition (CN) agencies
in California, Arizona, and Georgia about contacting the SFAs to participate in the study’s

The study will include districts that (1) had at least 61 households that did not respond to the verification request,
and (2) at least 41 households that responded and had no change in certification status resulting from the verification
process. The number of households for each criterion is the minimum starting sample size to achieve the target
number of completed surveys, assuming response rates of 68 percent and 78 percent, respectively.

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 3
pretest, and the Regional Offices asked the State CN directors to provide Mathematica with
current SFA information. This included contact information for the SFA director and an
indication of whether or not any applications were verified for cause in the fall of 2016. After the
State CN directors emailed Mathematica this information, Mathematica began contacting the
SFAs by email and follow-up phone calls. The email explained the goal of the pretest and
requested SFA directors’ help with: (1) testing the district interview, (2) reviewing the fall and
spring data requests, and (3) providing contact and demographic information for about 10 to 25
households in the 2016 verification sample. 2
Three of the five selected districts participated in the pretest. These participants completed
the pretest activities during 1 to 1.5 hour phone calls with trained Mathematica staff from
February 9 -15, 2017. Participant characteristics are presented in Table 1. We include more
information regarding the methodology and findings for each of the pretest components below.
Table 1. District characteristics

Respondent

State

District size
(number of students)

Did the district have any
questionable applications
that were verified for
cause in fall 2016?

Number of applications
verified for cause

California

14,437

n.a.

Arizona

48,455

Yes

30 applications

Georgia

111,751

Yes

25 applications

n.a. = not applicable

District interview

Methodology. Trained project staff conducted district interviews by phone. During the call,
the interviewer took notes on the responses to the questions in the interview protocol, the
administration time needed for each interview, and any issues related to wording and general
understanding of the interview questions. Two of three interviews were audio-recorded for later
playback and analysis. One SFA director preferred not to be recorded. We edited the district
interview based on feedback from the first interview so that we could pretest the changes in the
second two interviews. The second version of the survey with tracked changes is included in
Appendix A.
In addition to testing interview procedures, flow, and administration times, interviewers
used spontaneous probes when respondents hesitated or expressed confusion during the

We requested that all 3 of the districts provide Mathematica with sample for the Household Survey. However, for
logistical reasons we only conducted household interviews in AZ where we had staff who could easily conduct in
person interviews.

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 4
interview. The probes were designed to (1) determine whether any of the questions would be
difficult for respondents to comprehend or recall, and (2) ascertain whether the questions were
capturing information on intended constructs. This is a useful technique in pretesting, because
interviewers can get immediate feedback on specific questions from pretest respondents while
their responses are still fresh in their minds. This technique typically increases the length of
pretest interview administration by a few minutes, and this increase should be kept in mind when
interpreting average interview lengths from our pretest results.
Pretest Findings. During pretests, interviewers probed respondents when they hesitated or
expressed confusion, which assisted us in identifying problematic questions and making
necessary adjustments. For example, questions in Sections A and C were reordered to improve
flow and clarity, transition and instruction language was updated, and we clarified when we were
asking about verification or verification for cause.
The average length of the district interview for the three pretest respondents was 26 minutes
(20 minutes, 24 minutes, and 34 minutes, respectively). As noted above, question probes added a
burden of several minutes to each interview, so the administration time may be an overestimate.
However, we thought it was necessary to cut a few problematic questions in order to reduce the
administration time further. With these adjustments we estimate the district interview will take
approximately 20 minutes to complete over the phone. This is more than our originally proposed
15-minute interview, but we see value in adding 5 minutes so that we have enough time get
additional information about this topic. See Table 2 below for further details and information.
Table 2. Issues identified during pretest and modifications to the district interview
Interview section
Section A: Selecting
Applications for
Verification

Issue

Resolution

One of the respondents reported the
district did not select any applications
for cause. We anticipate some study
districts will not have selected any
applications for cause.

We edited the introduction instructions to
explain that even if the district has not
selected any applications for verification for
cause we are interested in knowing about
their process for selecting for cause because
all districts have an obligation to verify all
questionable applications.

In the question that was originally 1a,
respondents felt compelled to review
their whole verification notification
process and interviewers found it
hard to effectively code the
information as the question was
originally written. Also, interviewers
found that the information provided
for question 1a was largely
redundant with the information
provided for A-1b and 1c.

We dropped this question.

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 5
Interview section

Section B: Selecting
Applications for Cause

Issue

Resolution

In the questions that were originally
A-1d and 1e (Currently they are A-1a
and 1b), all respondents said that the
reference period of before two weeks
versus after two weeks was difficult
for them recall. Respondents could
easily tell the interviewers the total
time period that they attempted to
contact households and the number
of contacts via mail, phone, email,
and text message they made to
households throughout that period.

We rewrote the questions so that respondents
tell us the total amount of time their district
continues to contact households before they
mark them as nonresponsive. The follow up
question asks for the number of letters,
emails, follow-up phone calls, and text
messages the district will send during this
timeframe.

At B4a-e, when respondents
answered “no” to these sub-items,
they always volunteered more
information regarding why they did
not use the criteria.

We added an instruction to capture this
information if the respondent volunteers it. If
the SFA does not volunteer this information
then we will not probe.

SFA directors had trouble answering
what was originally question B-5. The
answers they provided were
estimates (one called it “a total
guess”). The directors said that
he/she would need to verify his/her
answers with timesheets. One
commented that the answer
depended on how many applications
were selected for cause during the
month, which is highly variable
throughout the year.

We dropped this question because
respondents were unsure they could provide
accurate answers during the interview. Given
concerns about instrument length and that
this is a low priority item for analysis we
dropped this.

At what was originally B-6 (Currently
B-5), respondents were having
trouble understanding this question
as it was written. Interviewers had to
repeat and use the probe which
usually clarified the question. SFA
directors tended to want to talk about
the process for selection rather than
the process after the household was
selected.

We reworded this question to clarify that we
are interested in the SFAs process once
households are selected.

None.

Given concerns about instrument length and
that this question does not answer a research
question we dropped what was originally
question B-7 in the survey.

At what was originally B-8 (Currently
B-7), respondents requested to have
this question reread several times
before they fully comprehended what
we were asking.

We reworded the question and underlined
sections to emphasize the distinction between
the processes of approval and confirmation.

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 6
Interview section

Issue

Resolution

Section C: Direct
Verification

At what was originally C-10
(Currently C-9), the interviewers
found that the “If not mentioned
above” text was confusing because
this is important information to gather
in the interview. The interviewer also
found that the question order in this
section did not flow well.

We removed “If not mentioned above” from
the stem of the question. We also added
yes/no response options and defined the skip
logic for the interviewer. If the respondent
answers that the district does not conduct
direct verification as a part of verification for
cause then the interviewer will ask why the
district does not do so. If the respondent does
do direct verification as a part of verification
for cause then the interviewer will ask the
follow-up questions.

In what was originally C-10a
(Currently C-9a), the interviewers
found that the probe in this question
contains key information about how
often a district conducts verification
as part of verification for cause. This
information should be collected if the
respondent does not detail it in their
answer. This is not optional
information to collect.

We added interviewer instructions, “If not
mentioned, probe….” to highlight that we want
to collect information about how often this
process occurs. The interviewer should ask
this question specifically if the respondent
doesn’t include the information in his/her initial
response.

In what was originally C-11
(Currently C-9b), interviewers had to
ask the question several times before
respondents fully comprehended it.

We added extra text clarifying that the
question was comparing processes used for
direct verification, and verification for cause.

One respondent said that the
verification for cause notification
process is the same as the
notification process for verification.
This comment refers to the original
questions D-12, 12b.1, and 12b.2
(currently they are D-11a, b, c, d, e)

We suggest reorganizing this section so that it
mirrors the flow of the questions in the first
section. If respondents say their verification
for cause notification process is the same as
their verification process then they could skip
out of this series of questions. We added a
question that was originally mentioned in the
probe of D-11a to ask about whether the
district uses the “We Must Check Your
Application” letter that FNS drafted. We also
added this question to the Section A question
about verification.

In what was originally D-12b
(Currently D-11.1 and 11.2), the
interviewers noticed that this item
contained multiple questions, making
it difficult for the respondents to
address all components of the
question.

We divided this question into two parts to
ensure all components are addressed.

In what was originally D-12b.2 and
13 (Currently D-11b.2 and 12), it was
difficult to code the respondent’s
answers in a “mark one only”
question.

We made this an open-ended question, so
that we can accommodate answers such as,
“right away” or “that same day.”

Section D: Notifying
Households

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 7
Interview section

Issue

Resolution

In what was originally question D-14,
respondents provided answers like,
“it varies” and that “sometimes
people never respond.” It was difficult
for the respondents to give an
accurate answer.

We dropped this question because
respondents cannot provide an accurate
answer. Also, given concerns about
instrument length and that this is a low priority
item for analysis we dropped this.

Section E: Assessing
Household)

In what was originally E-15 (Currently
E-13), the interviewers noticed this
question asks about special
procedures for siblings, but the
details of these procedures are
missing from the question stem.

We moved to the question stem the probe
asking about the special procedures for
siblings.

Section F: Finalizing
the Verification for
Cause Process

In what was originally F19 (Currently
F-17), the probe in this question
contains key information that we
want to collect.

We added interviewer instructions, “If not
mentioned, probe….” to highlight that this
information is needed and should be asked if
respondents do not include this information in
their answers.

Data requests

Methodology. We emailed the Verification Data Request and the Reapplication Data
Request to SFA directors one week before the pretest. We also included data file Excel templates
to help respondents visualize the type of data file that we would like to receive. We asked SFA
directors to review these materials before the pretest, but not to complete the data requests in
order to limit burden. During pretesting, interviewers used a debriefing guide to structure a 5 to
10-minute conversation about the SFA directors’ reaction to the request. This conversation
occurred after the district interview was completed. Two of the three conversations were
recorded. During this conversation the interviewer asked about and took notes on the burden of
the request, clarity of the materials, and utility of the templates provided. Both data requests can
be referenced in Appendix B.
Pretest findings. Overall, respondents found the data request and templates to be clear and
manageable. Therefore, these data requests did not require extensive updates. One SFA director
expressed some confusion regarding which year’s verification sample we were requesting. This
may be because an audit of the previous year’s verification sample will occur during this same
period. We have bolded and underlined “2017 verification sample” in the recruitment letter,
recruitment script, and data request form. Regarding the Reapplication Data Request, one SFA
director reported some confusion about the date range intended by “this year’s verification
determination date.” We updated this language to specify that in most districts, verification is
completed between mid-October and mid-November.
We estimate that the Verification Data Request will take districts an average of 4 hours to
complete and the Reapplication Data Request will average 1 hour. There is some uncertainty
attached to these estimates since school districts did not complete the full requests during the

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 8
pretest, but were instead asked to estimate the level of effort based on a more limited interaction.
The very small sample size of SFA directors participating in the pretest (3) and their lack of a
consistent approach in calculating and sharing an estimated administration time limits the
conclusions we can draw about the full level of burden this collection will entail. We do
anticipate that there will be considerable variation in effort across districts depending on size, the
way districts organize their verification data, and the accessibility of their data systems. Some
more details about the districts perceptions of burden related to calendar time are described
below.
Burden of the Verification Data Request. Feedback regarding SFA directors’ perceptions
of the burden of this request with regards to calendar time it would take to complete this request
varied. The directors of the two smaller SFAs reported they could provide data electronically by
December 15th, and that it would take about two weeks to respond to the request. Although one
of these SFA directors reported this request would not be difficult to fulfill, the other noted the
district works with a vendor who manages their verification process tracking system. This
director explained, that the request might be time-consuming if the vendor had trouble creating a
report that includes the data needed for the request (including more difficult items such as the
number of individuals in household with income). She said obtaining some of the data may
require manually sifting through applications, but her district should be able to handle the request
because of its relatively small enrollment. She added that she would need to coordinate with her
IT department to determine whether she could provide data in an Excel format.
The director of the largest district reported that because most of these data in the request are
not already part of the SFAs regular December report that is submitted to the State, it would take
her about one month to complete the request. The director went on to say she could not begin
work on the data request before mid-November, because her district is typically busy in early
November with an audit of the previous year’s verification sample. This director also mentioned
that because her district is focusing on the audits in addition to the current year’s verification
sample, she doubts her district could provide the data requested by December 15. However,
when the interviewer mentioned that Mathematica could send a trained data collector to her
district to help her abstract the necessary data from applications, she agreed the December 15
deadline was realistic.
The size of the largest district may have also contributed to this director’s hesitation to meet
the December 15th deadline. In preparation for working with districts that may be hesitant or
slow to respond, the study team has developed a set of strategies to ensure it meets data
collection targets. If the SFA director indicates that she or he is too busy to help with this request
then we will offer to provide in-person data collection support as mentioned above, stress that
study cooperation is required under the Healthy, Hunger-Free Kids Act of 2010, and identify
other or additional staff at the district who may be knowledgeable about administrative data and
are able to help. If the SFA director indicates that she or he is still reluctant to participate in the
study then we will reach out to Regional Office directors for support and emphasize
Mathematica’s dedication to security.

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 9
Burden of the Reapplication Data Request. All three SFA directors reported this request
was relatively low burden and that they would be able to gather this information by March 30,
2018. Directors reported it would take two to three weeks to gather these data and that they could
provide all of this information electronically via the secure file transfer site.
III. Household Pretest

Methodology

An experienced Mathematica researcher and specialist conducted a walkthrough of the
household survey with the two interviewers before the start of household recruitment. During
this training we also discussed the goals of the study, the verification process, and characteristics
of the study population.
Because one of the districts that participated in our pretest was near to our Survey
Operations Center in Tucson, AZ all pretest interviews were conducted in that location.
Interviewers used a paper-and-pencil version of the instrument. We used paper-and-pencil
because the computer-assisted personal interview (CAPI) instrument has not yet been developed;
we will incorporate findings from the pretest into the final CAPI instrument. We decided to not
pretest Section I because this section is heavily reliant on programming and it would have been
hard for the interviewers to do the necessary math on the fly.
Interviewers used the pretests primarily to test survey procedures, check the flow of survey
items, and estimate administration times. In addition, interviewers occasionally used spontaneous
probes during the interviews in a manner similar to their use in the district interview pretest
described above. The English and Spanish instruments that were used for the pretest are included
in Appendix C.
2.

Household recruitment

We asked the SFA directors to provide us with a list of 10 to 25 households in their 2016
verification sample to identify candidates for the household survey pretest. We requested the
following information for each household: parent or guardian’s contact information (name,
primary language, address, phone number, and email); name of student; name of the student’s
school; whether or not the household responded to the verification request; and if possible,
alternate contact information (work or emergency phone numbers). As part of the request to
SFAs we also requested a mix of households that did and did not respond to the verification
request as we will be working with both of these types of respondents during data collection.
Lastly, we asked directors for Spanish- and English-speaking parents/guardians. To protect the
privacy of pretest participants, we asked directors to provide us with this information over the
phone rather than via email.
After we received the household sample from the SFA directors, we trained two
interviewers on how to recruit households and conduct the survey. Interviewers were
experienced, bilingual field staff based in Mathematica’s Survey Operations Center in Tucson,

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 10
Arizona. Interviewers used the call script we developed for data collection (with a few minor
revisions) to talk to households about the study and set up interviews. Although we plan to send
advance materials to households during data collection, we did not send such materials before
the pretest due to time constraints. The interviewers began calling households in the sample on
February 20 and completed five interviews with households who responded to the district’s
verification request by March 4, 2017 (see Table 4 for respondent characteristics).
Recruiting nonresponding households was challenging. Overall, the interviewers found that
household contact information was not always accurate and respondents in this group were more
likely to refuse to participate. During the pretest, one survey took place with an individual who
did not respond to the fall verification request (Table 4). However, this person was very
uncomfortable having the interviewer come to her home to conduct the survey. The interviewer
offered to meet her in a neutral location (for example, a coffee shop), but the respondent was not
willing to do this. To complete the pretest the interviewer offered to conduct the survey over the
phone with the respondent. We do not expect to offer this phone option for the study; however,
we may discuss the approach with FNS during data collection if we are unable to reach response
rate targets through in-person administration.
Table 4. Household survey respondent characteristics
Respondent
identification number

Did the household respond
to the verification request?

Language of survey

Mode of survey

Yes

Spanish

In person

Yes

Spanish

In person

Yes

Spanish

In person

Yes

English

In person

Yes

English

In person

English

On the phone

Findings

Overall, the interviewers reported that the survey instrument worked very well. We
uncovered a few issues with missing response categories and skip logic and fixed them in the
final instruments. ). In addition, we found that the call script was an effective tool for the
interviewers to use during recruitment (see Table 5).

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 11
Table 5. Issues identified during pretest and modifications to the household survey
Interview section

Issue

Proposed resolution

n.a.

Respondents commented that they were not fully
confident in their ability to answer questions
about their household’s income in October 2016
in Sections E, F, G, and H. In general, it was
difficult for respondents to provide income
documentation for October 2016.

We will maintain the reference date of
October 2017 in the survey for
analytical consistency. However, we
acknowledge there may be some
effects on the data due to recall error.

Section C:
Perceptions of
School Meals

At C2b, respondents did not have an opinion
about the school lunches because they did not
have any knowledge of the lunches themselves.
Respondents did not feel like they could answer
the question.

We added a “Don’t know” option for
the interviewer to read aloud for C2a
and b.

Section D:
Perceptions of the
Verification Process

At D3, respondents could often recall receiving a
letter, email, or phone call. However,
respondents could not easily recall whether this
communication was from the school or district.
As the question is currently written the
interviewer would need to code “don’t know”
even if the respondent remembered receiving the
letter, email, or phone call because they could
not remember who tried to contact them.

We simplified this question to only
ask whether the respondent was
contacted by letter, email, or phone.
We also added an additional option
for contact by text message. Because
pretest respondents were unable to
recall whether they were contacted by
the school or the district, we dropped
this distinction.

At D14b-D14g a respondent didn’t know how to
respond because she said her household does
not receive that type of income. The respondent
didn’t feel comfortable selecting “Didn’t need to
provide” since she interpreted that response to
mean that she received this source of income but
the district didn’t request her to provide it.

In the D8 and D14 series, we
changed the response of “Didn’t need
to provide” to Not Applicable.

The interviewers noted that the contact
information for the households that did not
respond to the verification request was not as
reliable as that from the households in the
sample that did respond to the verification
request.

We added a series of questions (D11D13) to ask households that did not
respond to the verification request
about whether they moved or their
cell and/or home phone numbers
changed since the beginning of the
school year.

One interviewer noted that the fill at G6 is
awkward because the phrase “income for paid
work” does not seem to fit for all sources. Pretest
participants also asked the interviewer if the
question still applied to October 2017.

We deleted the phrase “income for
paid work” so that the fill works
properly. We also added text
indicating that for the question is
about the sources of income for
October 2017.

The interviewer noted that G9 did not seem
applicable to people who not in the labor force.
For example, one respondent was a stay-athome mother and the line of questioning about
what makes it hard for people to find or keep a
job did not apply to her.

We added instructions to clarify that if
a respondent is not in the labor force
then they should answer as though
they were looking for a job. We are
also requiring that all respondents
answer this question regardless of
whether they received income from
paid work.

Section G: Income
and Earning
Sources

MEMO TO: Courtney Paolicelli
FROM: Meg Bishop, Cheryl DeSaw, Bryce Onaran, Rachel Sutton-Heisey, and Eric Zeidman
DATE: 3/23/2017
PAGE: 12
Interview section
Section H: Income
and Earning
Amounts

Issue

Proposed resolution

The interviewer noted that at H8 and H18, if a
respondent would provide a W-2 as
documentation then this would include
information for the whole year.

We added a response option that
says “ENTIRE YEAR OF 2017
(CURRENT YEAR).”

n.a. = not applicable.

The average length of survey administration for the three pretest respondents was 43
minutes and 5 seconds (Table 6). This is consistent with the 45 minute burden estimate that we
were anticipating. Based on our past experience with similar pretests for instruments that were
later programmed in CAPI, we anticipate the CAPI version will reduce the average duration of
the paper-and-pencil administration by approximately five minutes. We do not recommend any
additional cuts to the survey to reduce burden based upon the pretest findings. Given the fact
that Section I was omitted from the pretest timings, we feel comfortable with the burden estimate
of 45 minutes.

Section B

Section C

Section D

Section E

Section F

Section G

Section H

Section I*

Section J

Section K

Total

Section A

Respondent

Table 6. Timing table for household survey administration

:25

1:00

3:12

3:47

5:24

2:16

6:16

3:10

n.a.

5:08

:03

31:08

:45

1:30

3:20

5:18

5:49

5:04

12:42

5:14

n.a.

6:22

:05

46:04

:29

1:45

4:02

4:29

6:31

3:08

3:24

4:07

n.a.

6:54

:06

34:40

:13

6:36

1:08

4:36

12:22

2:54

8:27

9:58

n.a.

3:59

:04

50:17

:58

2:54

4:42

5:59

4:19

10:36

4:44

4:22

n.a.

12:24

:04

51:02

1:17

1:55

2:48

9:43

8:41

2:34

6:05

9:29

n.a.

2:25

:23

45:20

Average

:41

2:37

3:12

5:38

7:11

4:25

6:56

5:16

n.a.

4:57

:09

43:05

a We decided not to pretest Section I because this section relies heavily on programming and interviewers might have
found it challenging to make the necessary calculations on the spot.
n.a. = not applicable.

APPENDIX A
DISTRICT INTERVIEW
PRETEST INSTRUMENT

This page has been left blank for double sided copying.

School Meal Application Study
Semi-Structured Interview

Name: ________________________________________________________________________

School District: ________________________________________________________________

Phone #: _____________________________________________________________________

START TIME: |__|__|:|__|__| AM PM

During this interview, we will talk about your verification process and reasons for selecting
applications for cause. Even if your SFA did not verify any applications for cause this year, we
would still like to ask you questions about your verification for cause process.
PROBE:

SFAs have an obligation to verify all questionable applications. This is known
as “verification for cause.” Such verification efforts cannot delay the approval
of applications. If an application is complete and indicates that the child is
eligible for free or reduced-price meals, the application must be approved at
face value. Only after determining eligibility can the school begin the
“verification for cause” process.

Section A: Selecting Applications for Verification
Before we discuss your district’s “verification for cause” process, we will talk about your district’s
process for selecting applications for verification.
1a.

How do you notify households that their application has been selected for verification? Do
you contact them by . . .
PROBE: Please include in your answer whether or not you send letters, emails, text

message or make telephone calls.

1b.

□
□
□
□

Telephone
Mail
Email
Text messaging

IF THE DISTRICT SENDS A LETTER/EMAIL/TEXT MESSAGE: Can you provide us with the
letter, email, and/or text message that your district sends to households?
IF NO: Ok, no problem.
IF YES: Great, can you please send this letter, email, and/or text message to me after we
have completed the interview?

1c.

When contacting them, does your district use the household’s preferred language to
communicate?
1
0

1d.

□
□

Yes
No

Thinking about the households that respond within two weeks of the initial notification,
about how many times does your district contact these households to inform them that
their application has been selected for verification?

PROBE:

Include the number of letters sent, emails sent, text messages sent, telephone
calls made.

|__|__| NUMBER TIMES CONTACTED
1e.

Thinking about the households that respond after two weeks of the initial notification,
about how many times does your district contact these households?
PROBE:

Include the number of letters sent, emails sent, text messages sent, telephone
calls made.

|__|__| NUMBER TIMES CONTACTED

Section B: Selecting Applications for Cause
Now, we will talk about how your SFA selects applications “for cause.”
1f.

When does your SFA select applications for "verification for cause”?
_____________________________________________________________________________
_____________________________________________________________________________

1g.

How often does your SFA select applications for “verification for cause”?
PROBE:

Does your SFA select applications on a rolling basis or just once or twice a
school year?

_____________________________________________________________________________
_____________________________________________________________________________
2.

Does your SFA have formal written criteria, or a related policy, that you use to identify
applications for “verification for cause”?
1
0

□
□

Yes
No

GO TO Q4

What formal criteria does your SFA use to identify applications for “verification for
cause”?
PROBE:

Here we just want to talk about any set standards that your SFA uses to identify
questionable applications. We are interested in your written standards.

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________
3a.

Is there any written documentation that you can share that outlines these criteria?
IF “NO” SAY: Ok, no problem.
IF “YES” SAY: Great! Can you please send this to us after we complete the interview?

IF “NO” IN QUESTION 2: What method(s) did you use to identify applications to verify for a
cause?
OR
IF “YES” IN QUESTION 2: Are there any other (informal) reasons why your SFA may
identify an application for “verification for cause”?
PROBE:

Informal reasons may include any reasons generally understood as standards
that may or may not be documented in writing.

Address the following questions if not covered in respondent's answers
above:
a. Does your SFA automatically “verify for cause” all non-responders from the
previous school year? .......................................................................................

MARK ONE PER ROW
YES

□

c. Does your SFA verify all applications that repeatedly list total income as $0 on
the application each year? ................................................................................

□

d. Does your SFA use available salary information to identify questionable
applications for school district employees? ......................................................

□

e. Does your SFA verify for cause when there are multiple application
submissions with different information? ............................................................

□

b. Does your SFA flag all error-prone applications and verify them for cause? ...
PROBE: Error-prone refers to those applications with an income listed within
$100/month ($1,200/year) above or below the eligibility limit for free meals or
$100/month ($1,200/year) below the eligibility limit for reduced-price meals.

Excluding time spent developing or revising the criteria, how much staff time does it take
to identify and pull applications for “verification for cause”?
PROBE:

Can you provide the total number of hours or days this takes staff?

|__|__| LENGTH OF TIME
1
0

□
□

Hours
Days

Once selected, what is your SFA’s process for verifying applications selected for cause?
PROBE:

What steps does your SFA take to verify identified applications? What are the
main activities in each of these steps?

How many staff are involved with the “verification for cause” process?
PROBE:
1
2
3
4

□
□
□
□

Please include all staff who are involved in the process, including secretarial
and clerical staff needed to produce materials and send out requests.

1 to 3
4 to 6
7 to 9
10 or more

What steps does your SFA take to ensure that the person who approved the applications
does not conduct the confirmation of the applications selected for verification?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

What steps does your SFA take to ensure employees are not approving their own
household’s applications or verifying their own applications?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Section C: Direct Verification
Let’s talk about direct verification of applications that have been selected for cause.
10.

If not mentioned above: Does your SFA conduct direct verification as part of verification
for cause?
1
0

□
□

Yes

GO TO Q10a

GO TO Q10b

10a. How does your SFA conduct direct verification?
PROBE: How often does your SFA conduct direct verification as part of verification for
cause?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

10b. Why doesn’t your SFA conduct direct verification as part of verification for cause?
If mentioned above: How does your SFA conduct direct verification as part of verification
for cause?
PROBE:

How does your SFA conduct direct verification as part of verification for cause?
How often does your SFA conduct direct verification as part of verification for
cause?

Does the direct verification process that your SFA conducts as part of verification for cause
differ from the regular direct verification process used for other applications? If so, how?

Section D: Notifying Households
12a.

What are your procedures for informing households that their application has been
selected for “verification for cause?”
If not mentioned: Does your SFA send a “Notification of Selection” letter and/or email?
When do you send the letter and/or email? Does your SFA also make follow-up phone
calls or send text messages to households?
PROBE:

What are the steps your district takes to notify households that their application
is being verified?

How many times does your SFA attempt to contact the households selected for
“verification for cause”?
PROBE: Include the number of letters sent, emails sent, text messages sent, telephone
calls made.
How many days, weeks, months?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

12b. 2 After the initial request for verification, how long does your SFA attempt to contact
non-responding households?
PROBE:

Include the number of letters sent, emails sent, text messages sent, telephone
calls made.
How many days, weeks, months?

_____________________________________________________________________________
12c.

13.

After selecting an application for verification for cause, how long does it take your SFA to
initially notify a household that its application has been selected for verification?
PROBE:

How many days, weeks, months?

14.

□
□
□

Days
Weeks
Months

Typically after the household is notified of the selection, how long does it take a
household to respond to the verification for cause request?
PROBE:

How many days, weeks, months?

□

Days

□

Weeks

□

Months

Section E: Assessing Household Information
15.

Does your SFA have any special procedures for siblings or children living at the same
address in your “verification for cause” process?
PROBE:

What are they?

What steps are taken when a household does not respond to the “verification for cause”
request?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

17.

What steps are taken when a household submits incomplete or incorrect
documentation/information during the “verification for cause” process?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

18.

What do you do if a household submits another application after its child(ren)’s
certification status has been terminated due to non-response in the same school year?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Section F: Finalizing the Verification for Cause Process
19.

After the household’s information has been reviewed, how does your SFA communicate
the results of the review to the household?
PROBE:

Does your SFA send a “Your Application Has Been Reviewed” letter and/or
email? If so, how soon after the household’s information has been reviewed do
you send a letter and/or email? What does the letter and/or email include?

How does your SFA report the results of the “verification for cause” process to your state
agency?
PROBE:

How does your SFA use the data collected during the verification period to
report to your state agency? What does your SFA report to your state agency?

What data from the “verification for cause” process are you required to report to your
state agency?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

22.

What information from the “verification for cause” process do you retain?
Where/how do you store this information?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Thank you for your time. Let me give you my contact information so you can send me the
letters/emails/text messages.

END TIME: |__|__|:|__|__| AM PM

This page has been left blank for double sided copying.

APPENDIX B
DATA REQUESTS
PRETEST INSTRUMENTS

This page has been left blank for double sided copying.

OMB No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

SCHOOL MEAL APPLICATION STUDY
Conducted on behalf of USDA Food and Nutrition Service
Phone: 1 (8XX)-XXX-XXXX
Email: [email protected]
HOUSEHOLD ADMINISTRATIVE DATA REQUEST PROTOCOL
This portion of the study will collect current information on all households in your district’s
2017 verification sample. Please provide the information listed on the following page for
each household in the verification sample.
For some fields we have provided recommended values or layouts in italics. Use of these
recommended values and codes is not required; however, if using alternative values or
codes, please include a data dictionary or codebook that defines the values. For your
reference we have included an Excel data file template attached to the email that you may
use as a guide when pulling together your district’s data file.
Please provide files in Excel (.xls, .csv, .xlsx), SAS (.sas, .sas7bdat), SPSS (.sav) or ASCII –
delimited or not (.txt) format. If you are unable to provide all of the information listed in an
electronic format the study team will work with you to find another alternative that is
convenient for you.
Please submit this file by December 15, 2017.
Once completed, please upload the data file and any documentation to our secure file transfer
website:
https://www.XXXXXX
Your username is: [USERNAME]
Please call [RECRUITER NAME at RECRUITER PHONE] (or the study team at
1 (8XX)-XXX-XXXX) for your SFAs private website password.
Note: This is a secure site that will help protect the privacy of the data. If you have any questions
about completing this data request, need assistance with the secure site, or with
zipping/encrypting files, please contact [RECRUITER NAME] at Mathematica, or a member of
the study team toll-free at 1 (8XX)-XXX-XXXX Monday through Friday, 9 a.m. to 5 p.m. (Eastern
Time) or [email protected].

***Please DO NOT email the data file or documentation***

REQUESTED DATA ITEMS
Current Household Verification Sample Information
Please provide the administrative data listed below for each household in your district’s verification
sample. This information will be used to select households to participate in a 45-minute survey.
Households will have the option not to participate in the study. No data will be retained on households
who do not consent to participate in the study.
Background information on households selected for verification:
1.

Household ID, or other unique household identifier, if available. If no identifier is available, please
assign a unique number to each household on the file.

Household size (number of people living in the household at the time application was completed)

Household monthly income at the time of application

Number of students in household enrolled at the time the verification sample was selected

Name(s) of student (s) in household

School(s) of student (s) in household

Grade level(s) of student(s) in household

Gender(s) of student(s) in household

A variable to indicate if the student is a foster child (yes/no, y/n, 1/2, etc.)

Information related to the original application for school meal benefits:
10. District’s initial determination of eligibility status (free, reduced-price, paid, not recorded)
11. A variable to indicate whether household was certified for free meals by application based on
categorical eligibility (participation in SNAP, TANF, or FDPIR) (yes/no, y/n, 1/2, etc.)
12. A variable to indicate whether household was certified for school meal benefits based on household
income reported on the application (yes/no, y/n, 1/2, etc.)
Information related to verification process:
13. A variable to indicate whether application was selected for cause (yes/no, y/n, 1/2, etc.)
14. Result of verification process (no change, free to reduced-price, free to paid, reduced-price to free,
reduced-price to paid, missing)
15. If there was a change in benefits after verification, reason for change in benefits (change in income
eligibility, household income, change in SNAP/TANF/FDPIR participation, refusal to cooperate, no
response, other (please specify), missing)
16. A variable to indicate whether application was directly verified (direct verification allows districts to
use records from public agencies to verify income or program participation) (yes/no, y/n, 1/2, etc.)

Locating information:
17. Parent/Guardian1 First Name
18. Parent/Guardian1 Last Name
19. Parent/Guardian1 Street Address, Line 1
20. Parent/Guardian1 Street Address, Line 2
21. Parent/Guardian1 City of Residence
22. Parent/Guardian1 State of Residence (2 letter code e.g. NJ, PA, TX, etc.)
23. Parent/Guardian1 Zip Code (5 digits)
24. Parent/Guardian1 Home Telephone Number (10 digits)
25. Parent/Guardian1 Cell Telephone Number (10 digits)
26. Parent/Guardian1 Work Telephone Number (10 digits + extension, if applicable)
27. Parent/Guardian1 Email Address
28. Parent/Guardian Language1 (English/Spanish/Other (please specify))
29. Parent/Guardian2 First Name
30. Parent/Guardian2 Last Name
31. Parent/Guardian2 Street Address, Line 1
32. Parent/Guardian2 Street Address, Line 2
33. Parent/Guardian2 State of Residence
34. Parent/Guardian 2 City of Residence
35. Parent/Guardian2 Zip Code (5 digits)
36. Parent/Guardian2 Home Telephone Number (10 digits)
37. Parent/Guardian2 Cell Telephone Number (10 digits)
38. Parent/Guardian2 Work Telephone Number (10 digits + extension, if applicable)
39. Parent/Guardian2 Email Address
40. Parent/Guardian Language2 (English/Spanish/Other (please specify))

Your username and password

To access the secure site, you need a username and password. Having discrete user information enhances
the security of your data as they reside on the secure site. No other states or districts will have access to
your district data. Anyone who has your username and password, and the location of the secure site, will
be able to access your data on the secure site, so guard this information carefully.
1. Username: [USERNAME]
2. Password: Call [RECRUITER NAME] at [RECRUITER PHONE] or toll free at 1-XXX-XXX-XXXX to
obtain your password. (Telephone is more secure than email for providing your password.)
B.

Preparing to upload the verification file

File format. As noted above, files can be in the format that is most convenient for you. Several
electronic formats such as Excel (.xls, .csv, .xlsx), SAS (.sas, .sas7bdat), SPSS (.sav) or ASCII –
delimited or not (.txt) format are acceptable. If you are unable to provide the data in an electronic format
the study team will work with you to find another alternative that is convenient for you.
Naming files. Include in the file names the district name, a sequential number, and the total number of
files you are uploading so we can easily identify them.
[DISTRICTNAME]_File[NUMBER SEQUENTIALLY]_of[TOTAL NUMBER OF FILES].[FILE TYPE]
For example, a single file in SAS: GREENVALLEY_File1_of1.sas7bdat
And naming multiple files in Excel: MAPLEWOOD_File3_of5.xls
Please note:

All files uploaded to the site must be encrypted with password protection using a
program such as WinZip for added security.

How to zip and encrypt/password protect your files using WinZip

REMINDER!
All files uploaded to the secure transfer site must be zipped and encrypted/password protected. After
the file is zipped, please call the study helpline at 1-XXX-XXX-XXXX to give us your password. Please
do NOT email the passwords.
Please note:

Keep the file password in a safe place. After the file is zipped and password protected,
the password will be required to open the file. Always keep an unzipped copy of the
file in the event the password is lost.

Zipping your file. If you have WinZip, the easiest way to zip a file is by the context menu method.
1. Navigate to the file on your local drive that you want to zip.
2. Right-click on the file.
3. From the WinZip option, select “Add to [NAME OF THE FILE].zip” (see file naming conventions
above.)

Using the WinZip default view
1. Select all of the files and/or folders in the open Zip file.
2. In the “Actions” pane, turn “Encrypt” on.
3. Click the “Options” drop-down menu in this pane and choose “Apply to Selected Files in the Zip”.
4. In the Encrypt dialog, enter the password in the “Enter Password” and “Re-enter Password (for
confirmation)” fields and then click “OK”.

Using the WinZip ribbon interface
1. In the main WinZip window, select all of the files in the WinZip file (Ctrl+A is a handy keyboard
shortcut).
2. In the “Tools” tab, click “Selected Files”.
3. Check “Encrypt Files” and click “OK”.
4. In the Encrypt dialog, enter the password in the “Enter Password” and “Re-enter Password (for
confirmation)” fields and then click “OK”.

Using the Legacy Toolbar interface
1. Choose “Encrypt” from the “Actions” menu.
2. WinZip will ask for a password and encryption method and then encrypt all of the files currently
in the Zip file.

Uploading verification files
1. Go to the secure file transfer site: https://xxxxxxxx
2. Enter your username and password.
3. Click the “Log in” button.
4. Click on the “Browse” button and select the files on your computer that you want to
upload to the site. Be sure the file is encrypted and password protected.
5. Click the “Upload” button.
6. Check the “Files for Mathematica” section to ensure the upload was successful.

After verifying the file is uploaded to the site, please send us an email to alert us that you have placed a
file(s) on the secure site; include the file name. Then, please call the study team toll free at 1-xxx-xxxx with
the file password—leave your name, your district name, and the file password.
Confirming file receipt. Mathematica will send an email confirming receipt of the files within two business
days.

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 control number. The valid OMB control number for this collection is xxxx-xxxx. The time required to complete
this information collection is estimated to average X hours per response, including the time to review instructions, searching
existing data resources, gather the data needed, and complete and review the information collected.

OMB No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

SCHOOL MEAL APPLICATION STUDY
Conducted on behalf of USDA Food and Nutrition Service
Phone: 1 (8XX)-XXX-XXXX
Email: [email protected]
REAPPLICATION AND CHANGES IN CERTIFICATION DATA REQUEST
PROTOCOL
As part of the School Meal Application Study, we will need to collect current information on:
•

Households that reapplied for free or reduced-price school meals between this year’s
verification determination date (in most districts verification is completed by November
15th) and 03/01/2018, and

•

Households that had any change to their certification status since the data you
provided on [XX/XX/2017].

Please provide the information listed on the following page for each household and/or
student who reapplied and/or had a change to their certification status as a result of
reapplication, direct certification, or any other reason. For some fields we have provided
recommended values or layouts in italics. Use of these recommended values and codes is
not required; however, if using alternative values or codes, please include a data dictionary
or codebook that defines the values. For your reference we have included an Excel data file
template attached to this email that you may use as a guide when pulling together your
district’s data file.
Please provide files in .xls, .csv, or .txt format. If you are unable to provide all of the
information listed in an electronic format the study team will work with you to find another
alternative that is convenient for you.
Please submit this file by March 30, 2018.
Once completed, please upload the data file and this form to our secure file transfer website:
https://www.XXXX.org
Your username is: [USERNAME]
Please call [RECRUITER NAME at RECRUITER PHONE] (or the study team at
1 (8XX)-XXX-XXXX) for the website password.
Note: This is a secure site that will help protect the privacy of the data. If you have any
questions about completing this data request, please contact [RECRUITER NAME] at
Mathematica, or a member of the study team toll-free at 1 (8XX)-XXX-XXXX or
[email protected].

***Please DO NOT email the data file or documentation***

REQUESTED DATA ITEMS
Please provide information listed below for each household that reapplied for free or reduced-price school
meals between this year’s verification determination date and 03/01/2018 and/or had a change in
certification status since the data you provided on [XX/XX/2017].
1. Household ID, or other unique household identifier, if available. If no identifier is available, please
assign a unique number to each household on the file.
Reapplication information
2. A variable to indicate whether or not the household reapplied for free or reduced-price school meals
between this year’s verification determination date and prior to March 1, 2018 (yes/no, y/n, 1/2, etc.)
3. Date of reapplication (mm/dd/year)
4. Certification status resulting from reapplication (free, reduced-price, paid)
5. Basis of certification status resulting from reapplication (categorical eligibility or income eligibility)
Direct certification information
6. A variable to indicate whether or not the household was directly certified (yes/no, y/n, 1/2, etc.)
7. Date of direct certification (mm/dd/year)
8. INSTRUCTION FOR RECRUITER: ONLY INCLUDE THIS QUESTION IF THE DISTRICT IS IN A
DIRECT CERTIFICATION WITH MEDICAID (DCM)-F/RP STATE: Certification status resulting from
direct certification (free, reduced-price)
9. Program that was the basis of direct certification (SNAP, TANF, FDPIR, Medicaid, Other)
Enrollment status information
10. A variable to indicate whether or not the student is still enrolled in the school (yes/no, y/n, 1/2, etc.)
11. IF STUDENT IS NO LONGER ENROLLED IN SCHOOL, last date of enrollment (mm/dd/year)

FILE TRANSFER INSTRUCTIONS
Below are instructions for preparing files for uploading files to the Mathematica secure transfer
site. To ensure confidentiality and privacy of data, we request that you upload your data files and
any supporting documentation to the secure HTTPS website below. Keeping data secure is very
important to Mathematica. Please do NOT email files – this is not a secure way to send
information. It is very important that you follow these instructions carefully. If you have questions,
please do not hesitate to call the toll-free study helpline at 1-XXX-XXX-XXXX.
Study secure transfer site location:
https://XXXXXXXX
A. Your username and password
To access the secure site, you need a username and password. Having discrete user information
enhances the security of your data as they reside on the secure site. No other states or districts will have
access to your district data. Anyone who has your username and password, and the location of the
secure site, will be able to access your data on the secure site, so guard this information carefully.
1. Username: [USERNAME]
2. Password: Call [RECRUITER NAME] at [RECRUITER PHONE] or toll free at 1-XXX-XXX-XXXX
to obtain your password. (Telephone is more secure than email for providing your password.)
B. Preparing to upload the verification file
File format. As noted above, files can be in the format that is most convenient for you. Several
electronic formats such as Excel (.xls, .csv, .xlsx), SAS (.sas, .sas7bdat), SPSS (.sav) or ASCII –
delimited or not (.txt) format are acceptable. If you are unable to provide the data in an electronic
format the study team will work with you to find another alternative that is convenient for you.
Naming files. Include in the file names the district name, a sequential number, and the total number
of files you are uploading so we can easily identify them.
[DISTRICTNAME]_File[NUMBER SEQUENTIALLY]_of[TOTAL NUMBER OF FILES].[FILE TYPE]
For example, a single file in SAS: GREENVALLEY_File1_of1.sas7bdat
And naming multiple files in Excel: MAPLEWOOD_File3_of5.xls
Please note:

All files uploaded to the site must be encrypted with password protection using a
program such as WinZip for added security.

C. How to zip and encrypt/password protect your files using WinZip
REMINDER!
All files uploaded to the secure transfer site must be zipped and encrypted/password protected. After
the file is zipped, please call the study helpline at 1-XXX-XXX-XXXX to give us your password.
Please do NOT email the passwords.
Please note:

Keep the file password in a safe place. After the file is zipped and password
protected, the password will be required to open the file. Always keep an
unzipped copy of the file in the event the password is lost.

4. The Zip file will appear with the original file in the same location.
The type of encryption that is used depends on the encryption settings in the Settings tab. When encrypting
your files, always select AES (256-bit) encryption.
To encrypt your new Zip archive:
A. Using the WinZip default view
1. Select all of the files and/or folders in the open Zip file.
2. In the “Actions” pane, turn “Encrypt” on.
3. Click the “Options” drop-down menu in this pane and choose “Apply to Selected Files in the Zip”.
4. In the Encrypt dialog, enter the password in the “Enter Password” and “Re-enter Password (for
confirmation)” fields and then click “OK”.
B. Using the WinZip ribbon interface
1. In the main WinZip window, select all of the files in the WinZip file (Ctrl+A is a handy keyboard
shortcut).
2. In the “Tools” tab, click “Selected Files”.
3. Check “Encrypt Files” and click “OK”.
4. In the Encrypt dialog, enter the password in the “Enter Password” and “Re-enter Password (for
confirmation)” fields and then click “OK”.

C. Using the Legacy Toolbar interface
1. Choose “Encrypt” from the “Actions” menu.
2. WinZip will ask for a password and encryption method and then encrypt all of the files currently in
the Zip file.
D. Uploading verification files
1. Go to the secure file transfer site: https://xxxxxxxx
2. Enter your username and password.
3. Click the “Log in” button.
4. Click on the “Browse” button and select the files on your computer that you want to upload to the
site. Be sure the file is encrypted and password protected.
5. Click the “Upload” button.
6. Check the “Files for Mathematica” section to ensure the upload was successful.
After verifying the file is uploaded to the site, please send us an email to alert us that you have placed a
file(s) on the secure site; include the file name. Then, please call the study team toll free at 1-xxx-xxxx
with the file password—leave your name, your district name, and the file password.
Confirming file receipt. Mathematica will send an email confirming receipt of the files within two business
days.

This page has been left blank for double sided copying.

APPENDIX C
HOUSEHOLD SURVEYS
PRETEST INSTRUMENTS
ENGLISH/SPANISH

This page has been left blank for double sided copying.

School Meal Application Study
Household Survey
DRAFT
February 22, 2017

START TIME: _______________________

INTERVIEWER: FOR THIS INTERVIEW OCTOBER 2017 SHOULD BE REFERRED TO AS OCTOBER
2016 ; SCHOOL YEAR 2017-2018 SHOULD BE REFERRED TO AS SCHOOL YEAR 2016-2017.

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.
A1.

CODE WITHOUT ASKING IF KNOWN, OR ASK: Is [TARGET STUDENT NAME] male or
female?
MALE .......................................................................................... 1
FEMALE ..................................................................................... 2

A2.

A3.

Does [TARGET STUDENT NAME] currently attend [TARGET SCHOOL]?
YES ............................................................................................ 1

(GO TO A4)

NO .............................................................................................. 2

(GO TO A3)

DON’T KNOW ............................................................................ 3

(GO TO A63)

STUDENT DECEASED ............................................................ 34

(GO TO A5)

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.
|___|___| / |___|___| / |___|___|
MONTH

DAY

(GO TO BOX AA)

YEAR
BOX AA

IF [TARGET STUDENT NAME] LEFT [TARGET SCHOOL] BEFORE 2017-2018 SCHOOL
YEAR, GO TO A6.
IF [TARGET STUDENT NAME] ATTENDED [TARGET SCHOOL] AT ANY POINT DURING
2017-2018 SCHOOL YEAR, GO TO A4.

A4.

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.
|___|___| / |___|___| / |___|___|
MONTH

DAY

(GO TO SECTION B)

YEAR

FIRST DAY OF SCHOOL .......................................................... 1

(GO TO SECTION B)

NEVER ATTENDED THIS YEAR............................................... 2

(GO TO A6)

A5.

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

A6.

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 END TIME: ________________

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.
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
B2.

DAY

MONTH

DAY

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.

a.
b.
c.
d.
e.

Monday, [DATE] .....................................................................
Tuesday, [DATE] ....................................................................
Wednesday, [DATE] ...............................................................
Thursday, [DATE] ...................................................................
Friday, [DATE] ........................................................................

YES

1
1
1
1
1

2
2
2
2
2

BOX BA
IF [TARGET SCHOOL] HAS A SCHOOL BREAKFAST PROGRAM, ASK B3; ELSE GO TO
BOX 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 BREAKFAST0 (GO TO B4)

If B3 = D
B3a.

Did (he/she) eat a school breakfast at least once?
YES ............................................................................................ 1
NO ............................................................................................ 20
DON’T KNOW/DON’T REMEMBER .......................................... d

BOX BB
IF B3 = 0, OR B3 = D AND B3A = 0 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 breakfastlunch at least once?
YES ............................................................................................ 1
NO ............................................................................................ 20
DON’T KNOW/DON’T REMEMBER .......................................... d
BOX BC
IF B4 = 0, OR B4 = D AND B4A = 0 OR D, SKIP C1D THROUGH C1F.

SECTION END TIME: ________________

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) …?

C1c.

The school breakfast meal program overall? Was
(she/he) …?

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) …?

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) …?

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 …?
C2a.

The school breakfast meal program overall? Are/Were
you …?

RESPONSE
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 …?
C2b.

C3.

The school lunch meal program overall? Are/Were
you…?

RESPONSE
Very Satisfied ........................ 1
Somewhat satisfied ............... 2
Somewhat dissatisfied .......... 3
Very Dissatisfied ................... 4
Student Never Eats Meals .... 5

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 …
C4.

Do you find the process…?

RESPONSE
Very fair ................................. 1
Somewhat fair ....................... 2
Somewhat unfair ................... 3
Very unfair ............................. 4
Don’t know ............................ d

SECTION END TIME: ________________

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 Application 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
If D1 = No
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 October or November 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 October or November of 2017?
YES ............................................................................................ 1

(GO TO D3)

NO .............................................................................................. 2
E1DA)

(GO TO BOX

DON’T KNOW ............................................................................ d
E1DA)

(GO TO BOX

REFUSED ................................................................................... r
E1DA)

(GO TO BOX

BOX DA
IF D1 = 1 or D2 = 1, GO TO D3. ELSE, GO TO E1.IF D1 = 2, 3, or 4 and D2 = 2, 3, or 4 go to E1.
If D1 = 1 or D2 = 1
D3.

When you were contacted did you receive…?
SELECT ALL THAT APPLY

a.
b.
c.
d.

A letter from the school .......................................................
A phone call from the school ..............................................
An email from the school ....................................................
A letter from the school district ..........................................

YES

1
1
1
1

2
2
2
2

DK REF
d
d
d
d

r
r
r
r

e.
f.

A phone call from the school district .................................
An email from the school district .......................................

1
1

2
2

d r
d r

If D3 a, c, d, or f = 1 and/or D3c and/or D3d and/or D3f = 1
D3_a. Was the (letter/email) in your preferred language?
YES ............................................................................................ 1
NO .............................................................................................. 2
DON’T KNOW ............................................................................ d
REFUSED ................................................................................... r
ASK NONRESPONDING HOUSEHOLDS (D4-D10).
If D1 or D2 = 1
D4.

Did you try to complete the request?
YES ............................................................................................ 1

(GO TO D5)

NO .............................................................................................. 2

(GO TO D58a)

DON’T KNOW ............................................................................ d

(GO TO D58a)

REFUSED ................................................................................... r

(GO TO D58a)

If D4 = 1
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

If D4 = 1
D6.

Don’t know/don’t remember ....................................................... 6

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 ....................................................... 6

If D4 = 1
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 ....................................................... 6

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…?

D8b

Income from child support? Would it have been…?

D8c

Income from unemployment, disability, or worker’s
comp? Would it have been…?

D8d

Income from Social Security, pensions, or
retirement? Would it have been…?

D8e

Income from welfare payments? Would it have
been…?

D8f

Income from the Military Housing Privatization
Initiative. Would it have been…?

D8g

Other income, such as rental income? Would it have
been…?

Very easy .............................. 1
Somewhat easy .................... 2
Somewhat difficult ................. 3
Very difficult........................... 4
Didn’t need to provide ........... 5
Very easy .............................. 1
Somewhat easy .................... 2
Somewhat difficult ................. 3
Very difficult........................... 4
Didn’t need to provide ........... 5

If all answers for D8a through D8g = 5
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

If D4 = 1
D10.

What are the most important reasons why you did not complete the request?
___________________________________________________ (STRING 250)
REASON
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................. r

ASK RESPONDING HOUSEHOLDS (D11-D17).
If D1 or D2 = 1
D11.

If D4 = 1
D12.

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

If D4 = 1
D13.

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

D14a

Income from your job? Was it…?

D14b

Income from child support? Was it…?

D14c

Income from unemployment, disability, or worker’s
comp? Was it…?

D14d

Income from Social Security, pensions, or
retirement? Was it…?

D14e

Income from welfare payments? Was it…?

D14f

Income from the Military Housing Privatization
Initiative? Was it…?

D14g

Other income, such as rental income? Was it…?

Very easy .............................. 1
Somewhat easy ..................... 2
Somewhat difficult ................. 3
Very difficult ........................... 4
Didn’t need to provide ........... 5
Very easy .............................. 1
Somewhat easy ..................... 2
Somewhat difficult ................. 3
Very difficult ........................... 4
Didn’t need to provide ........... 5

If all answers for D14a through D14g = 5
D15.

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

If D4 = 1
D16.
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
D17.

How much time did you spend completing the request? Was itDid it take…?.
Less than 30 minutes ............................................................... 1
30 minutes to an hour .............................................................. 2
One to two hoursMore than one hour but less than four
hours .......................................................................................... 3
Two to four hours ..................................................................... 4
More than four hours ............................................................. 45
Don’t know/don’t remember .................................................. 56

SECTION END TIME: ________________

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, gender, 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) _________________________
E2.

What is [TARGET STUDENT NAME]’s date of birth?
|___|___| / |___|___| / |___|___|
MONTH

E3.

DAY

YEAR

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.

E5.

YES ............................................................................................ 1

(GO TO E6)

NO .............................................................................................. 2

(GO TO E5)

May I please have the correct spelling of your legal name?
_________________________
FIRST NAME

E6.

_______________________
LAST NAME

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

E7.

(GO TO E17)

CODE IF KNOWN OR ASK: Does [TARGET STUDENT NAME] live with you?
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.
INTERVIEWER: DO NOT INCLUDE TARGET STUDENT.
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 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 E15 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 E15 FOR EACH PERSON.
____________________
RESPONDENT

E9.

What is [NAME]'s
relationship to
you?

E10. CODE GENDER.
IF NECESSARY,
ASK: Is [NAME]
female or male?
E11. What is (her/his)
date of birth?

FEMALE ........................... 1
MALE................................ 2

____________________
NAME #2

____________________
NAME #3

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, GREATAUNT, OR GREATUNCLE ......................... 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, GREATAUNT, OR GREATUNCLE .........................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
_____________________

FEMALE ........................... 1
MALE ............................... 2

FEMALE ...........................1
MALE ................................2

|___|___|/|___|___|/|___|___|
MONTH
DAY
YEAR

GO TO E13
Age will be calculated

E12. How old is
(he/she)?

A. YEARS ................ |___|___| A. YEARS ................ |___|___| A. YEARS ............... |___|___|

IF AGE IS AGE 5-18,
ASK E1310;
OTHERWISE, SKIP TO
E15.

YES .......... 1
NO ............ 2

B. MONTHS ............. |___|___| B. MONTHS ............ |___|___| B. MONTHS ............ |___|___|
YES .......... 1
(GO TO E153) NO............ 2

YES ..........1
(GO TO E153) NO ............2

(GO TO E153)

E13. Is [NAME]
currently
attending school?
E14. What grade is
(she/he) in?

E15. Did [NAME] live
with you in
October 2017?

|___|___| GRADE OR

PRESCHOOL ................... 1
KINDERGARTEN ............. 2
GRADES 1-2 .................... 3
GRADES 3-5 .................. 4
GRADES 6-8 .................... 5
GRADES 9-12 .................. 6
UNGRADED ..................... 7

PRESCHOOL ...................1
KINDERGARTEN .............2
GRADES 1-2.....................3
GRADES 3-5 ...................4
GRADES 6-8.....................5
GRADES 9-12...................6
UNGRADED .....................7

YES .................................. 1
NO .................................... 2

YES .................................. 1
NO.................................... 2

YES ..................................1
NO ....................................2

(GO TO NEXT PERSON)

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

ASK EVERYONE
E16.

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 E8 AND
ADD NAMES TO THE
HOUSEHOLD ROSTER)

E17.

For this next question, do not include temporary visitors. 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 you reported your income when [TARGET STUDENT
NAME]’s eligibility was checked for the school meals program benefits at [TARGET
SCHOOL].

E18.

YES ............................................................................................ 1

(GO TO E18)

NO .............................................................................................. 2

(GO TO E20)

How many other people lived with you in October 2017 that do not live with you now?
|___|
ADDITIONAL HOUSEHOLD MEMBERS

E19.

Please tell me the first name(s) of the other (person/people) that lived with you in October
2017 who 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 E19, LOOP BACK TO E8
AND ASK E9 TO E15 FOR EACH NAME.

ASK E20 TO E22 FOR EACH PERSON LISTED ON ROSTER UNDER AGE 18 AND NOT A FOSTER CHILD.
E20.

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.
E21.

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 E22 AND
E23.
REPEAT E22 AND E23 UNTIL EACH ADULT (16+) HOUSEHOLD MEMBER ON THE CREATED LIST IS
ASKED ABOUT EACH CHILD UNDER THE AGE OF 18.

E22.

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

E23.

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

E24.

ASK E24 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) _________________________

SECTION END TIME: ________________

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 SNAP or 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.

F2.

F3.

In October 2017, 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] benefits?
YES ............................................................................................ 1

(GO TO F3)

NO .............................................................................................. 2

(GO TO F2)

Did you, your spouse, and/or child/children receive SNAP benefits or [STATE NAME FOR
SNAP] benefits at any point during the 2017-2018 school year?
YES ............................................................................................ 1

(GO TO F3)

NO .............................................................................................. 2

(GO TO F7)

We need to verify that you and your child/children/you and your spouse and child/children
received [SNAP/STATE NAME FOR SNAP] benefits during the 2017-2018 school year. 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

F5.

F6.

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)

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.

F8.

F9.

In October 2017, 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

(GO TO F9)

NO .............................................................................................. 2

(GO TO F8)

Did you, your spouse, and/or child/children receive [TANF/STATE NAME FOR TANF]
benefits at any point during the 2017-2018 school year?
YES ............................................................................................ 1

(GO TO F9)

NO .............................................................................................. 2

(GO TO F13)

We need to verify that you and your child/children/you and your spouse and child/children
received [TANF/STATE NAME FOR TANF] benefits during the 2017-2018 school year. 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

F11.

F12.

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)

Do you share housing, income, or expenses with this person?
YES ............................................................................................ 1

(GO TO F13)

NO .............................................................................................. 2

(GO TO F13)

OTHER BENEFITS
F13.

F14.

F15.

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)

Did you, your spouse, and/or child/children receive FDPIR benefits at any point during the
2017-2018 school year?
YES ............................................................................................ 1

(GO TO F15)

NO .............................................................................................. 2

(GO TO G1)

We need to verify that you and your child/children/you and your spouse and child/children
received FDPIR benefits during the 2017-2018 school year. We can get that from your FDPIR
EBT card, award statement, or notification of payment. Do you have a FDPIR EBT card,
award statement, or notification of payment you can show me?
YES ............................................................................................ 1

(GO TO F16)

NO .............................................................................................. 2

(GO TO G1)

F16.

INTERVIEWER: WHAT KIND OF DOCUMENTATION DID THE RESPONDENT PROVIDE?
FDPIR EBT CARD ..................................................................... 1
AWARD STATEMENT ............................................................... 2
NOTIFICATION OF PAYMENT.................................................. 3
OTHER (SPECIFY) .................................................................... 4
NONE ......................................................................................... 5

SECTION END TIME: ________________

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.

G2.

YES ............................................................................................ 1

(GO TO G2)

NO .............................................................................................. 2

(GO TO BOX GB)

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)

G3.

How much is received monthly in Social Security benefits or disability survivors benefits?
$ |___|,|___|___|___|

G4.

How much is received monthly from persons outside the household?
$ |___|,|___|___|___|

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.
G6.

Let’s review each source of income. Did you receive [SOURCE 1] income for paid work?
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 #
Source 1

TYPE OF INCOME OR BENEFITS PAYMENT
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 #
Source 7

TYPE OF INCOME OR BENEFITS PAYMENT
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 #
Source 16

TYPE OF INCOME OR BENEFITS PAYMENT
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-G9
G7.

G8.

Have you worked for pay at any point during the 2017-2018 school year? 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

(GO TO G8)

NO .............................................................................................. 2

(GO TO G8)

DON’T KNOW ............................................................................ d

(GO TO G8)

REFUSED ................................................................................... r

(GO TO 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

G9.

Now I am going to read you a list of things that can make it hard for people to find or keep
a job. Please refer to the card when answering these questions.
Please tell me if each of the following has made it not at all hard, a little hard, somewhat
hard, very hard, or extremely hard for you to find or keep a job in the past year…
HAND SHOWCARD #7 TO RESPONDENT
CODE ONE PER ROW
NOT AT
A
ALL
LITTLE
HARD
HARD

SOMEWHAT
HARD

VERY
HARD

EXTREMELY
HARD

DON’T
KNOW

REFUSED

a. Problems getting to work,
such as not having a car or
access to public
transportation. .....................

Not having reliable
transportation b.
..............................................
Not having the kinds of
skills employers are
looking for ...........................

Not having the right
clothes for work c.
..............................................
Having to take care of a
family member.....................

Not having the required
documentation for
employment, such as a
birth certificate
d.
..............................................
Not having a steady place
to live....................................

Not having good enough
childcare or family
help
e.
..............................................
Alcohol or drug use. ...........

Having a criminal
record f.
..............................................
Trouble getting along with
other people or controlling
your anger. ..........................

Not having the right skills
or education g.
..............................................
Your physical health ...........

Having substance use or
mental health problems h.
..............................................
Having a criminal record ....

CODE ONE PER ROW
NOT AT
A
ALL
LITTLE
HARD
HARD

Trouble getting along
with other people or
controlling your angeri.
..............................................
Other ....................................

SOMEWHAT
HARD

VERY
HARD

EXTREMELY
HARD

DON’T
KNOW

REFUSED

SECTION END TIME: ________________

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, 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 the last time
(you were/[PERSON’S NAME]was) paid.
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 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: Do you have an earnings statement from October 2017?
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) _________________________

(GO TO H4)

DON’T KNOW _____________________________

(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

H5.

(GO TO H11)

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
STATEMENT .............................................................................. 8
BENEFITS LETTER ................................................................... 9
CHECK STUB .......................................................................... 10
OTHER (SPECIFY) .....................................................................

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 ....................................................................... 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 October 2017?
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 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.
ASK H12-H20 ABOUT EVERY OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT (16+)
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 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 G68], 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) _________________________

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
STATEMENT .............................................................................. 8
BENEFITS LETTER ................................................................... 9
CHECK STUB .................................................... 10STATEMENT

BENEFITS LETTER ................................................................... 2
CHECK STUB ............................................................................ 3
INCOME TAX RETURN ............................................................. 4
AWARD LETTER/CONTRACT .................................................. 5
OTHER (SPECIFY) _________________________
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 ....................................................................... 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?
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 [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 END TIME: ________________

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 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 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)

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) monthly income to be this school year?
USUAL AMOUNT ....................................................................... 1

(GO TO J1)

MORE THAN AVERAGE ........................................................... 2

(GO TO I5)

LESS THAN AVERAGE ............................................................. 3

(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 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 help 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) _________________________

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?
YES ............................................................................................ 1
NO .............................................................................................. 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
OTHER (SPECIFY) ................................................................... 6
REFUSED ................................................................................... r

J5.

Is English the primary language spoken in this household?
YES ............................................................................................ 1
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) _________________________

J7.

Are you a United States citizen?
YES ............................................................................................ 1
NO .............................................................................................. 2

(GO TO J7)

J8.

How long have you lived in the United States?
MY ENTIRE LIFE ....................................................................... 1
OR
SINCE |___|___|___|___| ........................................................... 2
YEAR
OR
IF NEEDED: Include the total number of years/months living in the United States.
|___|___| OR |___|___| ............................................................. 3
YEARS

MONTHS

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?
YES ............................................................................................ 1
NO .............................................................................................. 2

J10.

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
OTHER (SPECIFY) ___________________________

REFUSED .................................................................................. 7

SECTION END TIME: ________________

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.
SURVEY END TIME: ________________

This page has been left blank for double sided copying.

School Meal Application Study
Household Survey
DRAFT
(Spanish version)
February 22, 2017

SURVEY START TIME: ________________

INTERVIEWER: FOR THIS INTERVIEW OCTOBER 2017 SHOULD BE REFERRED TO AS OCTOBER
2016 ; SCHOOL YEAR 2017-2018 SHOULD BE REFERRED TO AS SCHOOL YEAR 2016-2017.

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.
A1.

CODE WITHOUT ASKING IF KNOWN, OR ASK: ¿Es [TARGET STUDENT NAME] hombre o
mujer?
MALE .......................................................................................... 1
FEMALE ..................................................................................... 2

A2.

¿Asiste [TARGET STUDENT NAME] a [TARGET SCHOOL] actualmente?
YES ............................................................................................ 1

A3.

(GO TO A4)

NO .............................................................................................. 2

(GO TO A3)

STUDENT DECEASED .............................................................. 3

(GO TO A5)

¿Cuándo dejó (ella/él) de asistir a [TARGET SCHOOL]?
PROBE:¿Eso fue a principios, a mediados o al final del mes?
IF BEGINNING OF MONTH, ENTER 1 FOR DAY; IF MIDDLE OF MONTH, ENTER 15 FOR DAY;
IF END OF MONTH, ENTER 30 FOR DAY.
|___|___| / |___|___| / |___|___|
MONTH

DAY

(GO TO AA)

YEAR
BOX AA

IF [TARGET STUDENT NAME] LEFT [TARGET SCHOOL] BEFORE 2017-2018 SCHOOL
YEAR, GO TO A6.
IF [TARGET STUDENT NAME] ATTENDED [TARGET SCHOOL] AT ANY POINT DURING
2017-2018 SCHOOL YEAR, GO TO A4.

A4.

¿Cuándo comenzó (ella/él) a asistir a [TARGET SCHOOL] durante este año escolar?
PROBE: Por “este año escolar” quiero decir el año escolar actual 2017- 2018.
PROBE: ¿Eso fue a principios, a mediados o al final del mes?
IF BEGINNING OF MONTH, ENTER 1 FOR DAY; IF MIDDLE OF MONTH, ENTER 15 FOR DAY;
IF END OF MONTH, ENTER 30 FOR DAY.
|___|___| / |___|___| / |___|___|
MONTH

DAY

(GO TO SECTION B)

YEAR

FIRST DAY OF SCHOOL .......................................................... 1

(GO TO SECTION B)

NEVER ATTENDED THIS YEAR............................................... 2

(GO TO A6)

A5.

Lamento mucho su pérdida. No haremos una entrevista. Gracias por su tiempo.
INTERVIEWER TERMINATE INTERVIEW.

A6.

Solo nos interesa hablar con padres o tutores del estudiante que asistió a [TARGET
SCHOOL] este año escolar. No necesitamos realizar una entrevista con usted. Gracias por
su tiempo.

SECTION END TIME: ________________

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.
Las siguientes preguntas son acerca de las comidas que come [TARGET STUDENT NAME] en la
escuela.
Voy a preguntar si su hijo(a) comió desayuno o almuerzo escolar algún día durante la última semana
completa de escuela. Me refiero a las comidas proporcionadas a través del Programa Nacional de
Desayuno Escolar y del Programa Nacional de Almuerzo Escolar. Estas son las comidas que se
ofrecen en el menú gratis o por un precio único, en lugar de comidas individuales, como ensaladas,
carnes y postres que tienen un precio y se compran por separado.
CODE WITHOUT ASKING IF KNOWN:
B1.

¿Cuándo fue la última semana completa de escuela?
NOTE TO INTERVIEWER: PLEASE USE CALENDAR TO ASSIST.
LAST WEEK ............................................................................... 1

FROM |___|___| / |___|___| TO |___|___| / |___|___|
MONTH
B2.

DAY

MONTH

DAY

Ahora, por favor piense en la última semana completa de escuela—eso sería (de lunes a
viernes de la semana pasada/de lunes—[DATE] a viernes—[DATE]).
¿Asistió su hijo(a) a la escuela el…?
PROBE: Por asistir a la escuela, queremos decir que su hijo(a) estaba en el escuela todo o
parte del día.
NOTE TO INTERVIEWER: IF RESPONDENT MAKES A STATEMENT ABOUT THE ENTIRE
WEEK, ENTER DATA FOR EACH DATE.

a.
b.
c.
d.
e.

Lunes, [DATE] ........................................................................
Martes, [DATE] .......................................................................
Miércoles, [DATE] ..................................................................
Jueves, [DATE] ......................................................................
Viernes, [DATE]......................................................................

YES

1
1
1
1
1

2
2
2
2
2

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

B3.

¿Cuántos días comió (él/ella) un desayuno escolar?
|___|
NUMBER OF DAYS ATE SCHOOL BREAKFASTS
DON’T KNOW/DON’T REMEMBER .......................................... d
NONE, DID NOT EAT BREAKFAST/SCHOOL BREAKFAST ... 0

If B3 = D
B3a.

¿Comió (él/ella) un desayuno escolar por lo menos una vez?
YES ............................................................................................ 1
NO .............................................................................................. 0
DON’T KNOW/DON’T REMEMBER .......................................... d

BOX BB
IF B3 = 0, OR B3 = D AND B3A = 0 OR D, THEN SKIP C1A THROUGH C1C.
B4.

¿Cuántos días comió (él/ella) un almuerzo escolar?
|___|
NUMBER OF DAYS ATE SCHOOL LUNCHES
DON’T KNOW/DON’T REMEMBER .......................................... d
NONE, DID NOT EAT LUNCH/SCHOOL LUNCH ..................... 0

If B4 = D
B4a.

SECTION END TIME: ________________

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.
Las siguientes preguntas son acerca de la satisfacción de [TARGET STUDENT NAME] con las
comidas de desayuno escolar en [TARGET SCHOOL].
HAND SHOWCARD #1 TO RESPONDENT
Con respecto a las comidas de desayuno escolar en
[TARGET SCHOOL], ¿qué tan satisfecho(a) estaba
[TARGET STUDENT NAME] con…

RESPONSE

C1a.

El sabor de la comida? ¿Estaba (ella/él)…?

C1b.

La cantidad de comida servida? ¿Estaba (ella/él)…?

C1c.

El programa de comidas de desayuno escolar en
general? ¿Estaba (ella/él)…?

Las siguientes preguntas son acerca de la satisfacción de [TARGET STUDENT NAME] con las comidas
del almuerzo escolar en [TARGET SCHOOL].
Con respecto a las comidas del almuerzo escolar en
[TARGET SCHOOL], ¿qué tan satisfecho(a) estaba
[TARGET STUDENT NAME] con…

RESPONSE

C1d.

El sabor de la comida? ¿Estaba (ella/él)…?

C1e.

La cantidad de comida servida? ¿Estaba (ella/él)…?

C1f.

El programa de comidas del almuerzo escolar en
general? ¿Estaba (ella/él)…?

Las siguientes preguntas son acerca de su satisfacción con las comidas del desayuno escolar en
[TARGET SCHOOL].
HAND SHOWCARD #2 TO RESPONDENT
Con respecto a las comidas del desayuno escolar en
[TARGET SCHOOL], ¿qué tan satisfecho(a)
está/estaba usted con…
C2a.

El programa de comidas de desayuno escolar en
general? ¿Está/Estaba usted…?

RESPONSE
Very Satisfied ........................ 1
Somewhat satisfied ............... 2
Somewhat dissatisfied .......... 3
Very Dissatisfied ................... 4
Student Never Eats Meals .... 5

Las siguientes preguntas son acerca de su satisfacción con las comidas del almuerzo escolar en
[TARGET SCHOOL].
Con respecto a las comidas del almuerzo escolar en
[TARGET SCHOOL], ¿qué tan satisfecho(a)
está/estaba usted con…
C2b.

C3.

El programa de comidas del almuerzo escolar en
general? ¿Está/Estaba usted…?

RESPONSE
Very Satisfied ........................ 1
Somewhat satisfied ............... 2
Somewhat dissatisfied .......... 3
Very Dissatisfied ................... 4
Student Never Eats Meals .... 5

Las siguientes preguntas son acerca de su satisfacción con el proceso de solicitud para comidas
escolares gratis y a precio reducido.
HAND SHOWCARD #3 TO RESPONDENT
Con respecto al proceso de solicitud para comidas
escolares gratis y a precio reducido…
C4.

¿El proceso le parece…?

SECTION END TIME: ________________

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 respond to the verification
request about why they did not respond.
INTRO TO SECTION: A continuación, me gustaría hacerle preguntas sobre sus experiencias con el
proceso de Solicitud para Comidas Escolares Gratis y a Precio Reducido.
ASK ALL HOUSEHOLDS
D1.

¿Le contactó el distrito escolar para verificar la exactitud de su solicitud durante este año
escolar?
YES ............................................................................................ 1

(GO TO D3)

NO .............................................................................................. 2

(GO TO D2)

DON’T KNOW ............................................................................ d

(GO TO D2)

REFUSED ................................................................................... r

(GO TO D2)

If D1 = No
D2.

Normas federales requieren que los distritos escolares verifiquen al azar un pequeño número de
aplicaciones cada año para asegurar que son exactos. Nuestros registros muestran que su
aplicación fue seleccionada en octubre o noviembre de 2017. El distrito escolar le hubiera
contactado y pedido a usted que proporcionara prueba de sus ingresos para verificar su
aplicación.
¿Le contactaron sobre eso en octubre o noviembre de 2017?
YES ............................................................................................ 1

(GO TO D3)

NO .............................................................................................. 2

(GO TO BOX DA)

DON’T KNOW ............................................................................ d

(GO TO BOX DA)

REFUSED ................................................................................... r

(GO TO BOX DA)

BOX DA
IF D1 = 2, 3, or 4 and D2 = 2, 3, or 4 go to E1.
If D1 = 1 or D2 = 1
D3.

Cuando le contactaron, ¿recibió…?
SELECT ALL THAT APPLY

a.
b.
c.
d.
e.
f.

Una carta de la escuela .......................................................
Una llamada por teléfono de la escuela .............................
Una correo electrónico de la escuela ................................
Una carta del distrito escolar ..............................................
Una llamada por teléfono del distrito escolar ...................
Una correo electrónico del distrito escolar .......................

YES

1
1
1
1
1
1

2
2
2
2
2
2

If D3a and/or D3c and/or D3d and/or D3f = 1
D3_a. ¿Estaba (la carta/el correo electrónico) en el idioma de su preferencia?
YES ............................................................................................ 1
NO .............................................................................................. 2
DON’T KNOW ............................................................................ d
REFUSED ................................................................................... r
ASK NONRESPONDING HOUSEHOLDS.
If D1 or D2 = 1
D4.

¿Trató de completar la solicitud?
YES ............................................................................................ 1

(GO TO D5)

NO .............................................................................................. 2

(GO TO D8a)

DON’T KNOW ............................................................................ d

(GO TO D8a)

REFUSED ................................................................................... r

(GO TO D8a)

If D4 = 1
D5.

¿Qué tan claras eran las instrucciones en la carta y formulario que acompañaron la
solicitud? ¿Diría que eran…?
HAND SHOWCARD #4 TO RESPONDENT
Very clear ................................................................................... 1
Somewhat clear .......................................................................... 2
Neither clear nor unclear ............................................................ 3
Somewhat unclear ...................................................................... 4
Very unclear ............................................................................... 5

If D4 = 1
D6.

¿Qué tan fácil hubiera sido completar la solicitud a tiempo? ¿Hubiera sido…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

If D4 = 1
D7.

¿Qué tan fácil hubiera sido proporcionar la información solicitada como talones de pago,
cartas o copias de talones de pago? ¿Hubiera sido…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

Las siguientes preguntas son acerca de qué tan fácil le hubiera sido proporcionar prueba de sus
ingresos.
HAND SHOWCARD #6 TO RESPONDENT
¿Qué tan fácil hubiera sido proporcionar prueba de…

RESPONSE

D8a

Ingresos de su trabajo? ¿Hubiera sido…?

D8b

Ingresos de manutención de hijos? ¿Hubiera sido…?

D8c

Ingresos por desempleo, incapacidad o
compensación de trabajadores? ¿Hubiera sido…?

D8d

Ingresos del Seguro Social, pensiones o jubilación?
¿Hubiera sido…?

D8e

Ingresos de pagos de beneficios sociales? ¿Hubiera
sido…?

D8f

Ingresos de la Iniciativa de Privatización de la
Vivienda Militar? ¿Hubiera sido…?

D8g

Otros ingresos, como ingresos de alquiler? ¿Hubiera
sido…?

If D8a through D8g = 5
D9.

¿Qué tan fácil hubiera sido proporcionar una breve nota explicando cómo proporciona
comida, ropa y vivienda a su hogar? ¿Hubiera sido…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

If D4 = 1
D10.

¿Cuáles son las razones más importantes por las cuales no completó la solicitud?
___________________________________________________ (STRING 250)
REASON
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................. r

ASK RESPONDING HOUSEHOLDS.
If D1 or D2 = 1
D11.

Qué tan claras eran las instrucciones en la carta y formulario que acompañaron la solicitud?
¿Diría que eran…?
HAND SHOWCARD #4 TO RESPONDENT
Very clear ................................................................................... 1
Somewhat clear .......................................................................... 2
Neither clear nor unclear ............................................................ 3
Somewhat unclear ...................................................................... 4
Very unclear ............................................................................... 5

If D4 = 1
D12.

¿Qué tan fácil fue completar la solicitud a tiempo? ¿Fue…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

If D4 = 1
D13.

Qué tan fácil fue proporcionar información como talones de pago, cartas o copias de
talones de pago que demostraron que su hijo(a) era elegible? ¿Fue…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

Las siguientes preguntas son acerca de qué tan fácil fue proporcionar prueba de sus ingresos.
HAND SHOWCARD #6 TO RESPONDENT
¿Qué tan fácil fue proporcionar prueba de…

RESPONSE

D14a

Ingresos de su trabajo? ¿Fue…?

D14b

Ingresos de manutención de hijos? ¿Fue…?

D14c

Ingresos por desempleo, incapacidad o
compensación de trabajadores? ¿Fue…?

D14d

Ingresos del Seguro Social, pensiones, o
jubilación? ¿Fue…?

D14e

Ingresos de pagos de beneficios sociales?
¿Fue…?

D14f

Ingresos de la Iniciativa de Privatización de la
Vivienda Militar? ¿Fue…?

D14g

Otros ingresos, como ingresos de alquiler.
¿Fue…?

If all answers for D14a through D14g = 5
D15.

¿Qué tan fácil fue proporcionar una breve nota explicando cómo proporciona comida, ropa
y vivienda a su hogar? ¿Fue…?
HAND SHOWCARD #5 TO RESPONDENT
Very easy.................................................................................... 1
Somewhat easy .......................................................................... 2
Neither easy nor difficult ............................................................. 3
Somewhat difficult ...................................................................... 4
Very difficult ................................................................................ 5

If D4 = 1
D16.
¿Cuáles son las razones más importantes por las cuales completó la solicitud que llegó de
la escuela?
____________________________________________ (STRING 250)
REASON
DON’T KNOW ............................................................................ d
REFUSED ................................................................................... r
D17.

¿Cuánto tiempo dedicó en responder a la solicitud? ¿Fue…?
Menos de 30 minutos ............................................................... 1
De 30 minutos a una hora ........................................................ 2
Una o dos horas ....................................................................... 3
Dos a cuatro horas ................................................................... 4
Más de cuatro horas ................................................................ 5
No sé/No recuerdo ................................................................... 6

SECTION END TIME: ________________

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, gender, 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: Ahora, me gustaría hacer preguntas sobre [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.

¿Qué relación o parentesco tiene [TARGET STUDENT NAME] con usted?

¿Cuál es la fecha de nacimiento de [TARGET STUDENT NAME]?
|___|___| / |___|___| / |___|___|
MONTH

E3.

DAY

YEAR

¿Vivió [TARGET STUDENT NAME] con usted en octubre de 2017?
YES ............................................................................................ 1
NO .............................................................................................. 2

Ahora me gustaría hacerle preguntas acerca de las personas que viven aquí con usted.
ASK EVERYONE
E4.

Tengo su nombre anotado como [PARENT/GUARDIAN NAME]. ¿Es correcto?
INTERVIEWER: SPELLING OF RECORDED NAME SHOULD BE CONFIRMED.

E5.

YES ............................................................................................ 1

(GO TO E6)

NO .............................................................................................. 2

(GO TO E5)

¿Podría deletrear su nombre legal?
_________________________
FIRST NAME

E6.

_______________________
LAST NAME

Sin incluirse a usted, ¿cuántas personas viven con usted? Por favor incluya bebés, niños
pequeños, personas que no son parientes y personas que están temporalmente ausentes,
por ejemplo, en la escuela o en un hospital.
|___|___|
PEOPLE LIVING IN HOUSEHOLD
NONE OR LIVES ALONE .......................................................... 1

E7.

(GO TO E17)

CODE IF KNOWN OR ASK: ¿Vive [TARGET STUDENT NAME] con usted?
YES ............................................................................................ 1
NO .............................................................................................. 2

E8.

Por favor dígame el nombre de todas las personas que viven aquí con usted.
FILL IN NAME OF RESPONDENT IN POSITION #1.
INTERVIEWER: DO NOT INCLUDE TARGET STUDENT.
PROBE: ¿Quién más vive con usted?
________________________
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

E9.

¿Qué parentesco
tiene [NAME] con
usted?

E10. CODE GENDER. FEMALE ........................... 1
MALE................................ 2
IF NECESSARY,
ASK:¿Es [NAME]
mujer u hombre?
E11. ¿Cuál es la fecha
de nacimiento de
(él/ella)?

____________________
NAME #2

____________________
NAME #3

FEMALE ........................... 1
MALE ............................... 2

FEMALE ...........................1
MALE ................................2

|___|___|/|___|___|/|___|___|
MONTH
DAY
YEAR

GO TO E13
Age will be calculated

E12. ¿Cuántos años
tiene (él/ella)?

A. YEARS ................ |___|___| A. YEARS ................ |___|___| A. YEARS ............... |___|___|

IF AGE IS AGE 5-18,
ASK E10;
OTHERWISE, SKIP TO
E15.

YES .......... 1
NO ............ 2

B. MONTHS ............. |___|___| B. MONTHS ............ |___|___| B. MONTHS ............ |___|___|
YES .......... 1
(GO TO E13) NO............ 2

YES ..........1
(GO TO E13) NO ............2

(GO TO E13)

E13. ¿Asiste [NAME] a
la escuela
actualmente?
E14. ¿En qué grado
está (él/ella)?

|___|___| GRADE OR

YES .................................. 1
E15. ¿Vivió [NAME]
NO
.................................... 2
con usted en
octubre de 2017?

YES .................................. 1
NO.................................... 2

YES ..................................1
NO ....................................2

(GO TO NEXT PERSON)

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

ASK EVERYONE
E16.

Acaba de decirme que [NUMBER OF PERSONS ON HOUSEHOLD ROSTER] persona(s)
vive(n) aquí con usted. Esto incluye [NAMES OF ALL REPORTED PERSONS]. Solo para
confirmar, ¿me ha dicho todas las personas que viven aquí, incluyendo bebés, niños
pequeños, personas que no son parientes y personas que están temporalmente ausentes,
por ejemplo, en la escuela o en un hospital?

YES ............................................................................................ 1
NO .............................................................................................. 2

(RETURN TO E8 AND
ADD NAMES TO THE
HOUSEHOLD ROSTER)

E17.

Para la siguiente pregunta, no incluya visitantes temporales. ¿Vivió alguien (más) con usted
en este hogar en octubre de 2017 que no vive con usted ahora?
IF NEEDED, ADD: Este es el mes en que indicó sus ingresos cuando se verificó la
elegibilidad de [TARGET STUDENT NAME] para los beneficios del programa de comidas
escolares en [TARGET SCHOOL].

E18.

YES ............................................................................................ 1

(GO TO E18)

NO .............................................................................................. 2

(GO TO E20)

¿Cuántas personas más vivieron con usted en octubre de 2017?
|___|
ADDITIONAL HOUSEHOLD MEMBERS

E19.

Por favor dígame el nombre de la(s) otra(s) persona(s) que vivieron con usted en octubre
de 2017 que ya no viven aquí con usted ahora.
______________________________
NAME OF OTHER PERSON # 1
______________________________
NAME OF OTHER PERSON # 2
______________________________
NAME OF OTHER PERSON # 3
BOX EC
FOR EACH ADDITIONAL HOUSEHOLD PERSON RECORDED IN E19, LOOP BACK TO E8
AND ASK E9 TO E15 FOR EACH NAME.

ASK E20 TO E22 FOR EACH PERSON LISTED ON ROSTER UNDER AGE 18 AND NOT A FOSTER CHILD.
E20.

En octubre de 2017, ¿pagó usted (o su cónyuge/pareja) algún gasto del hogar o proporcionó
apoyo financiero para [NAME OF EACH CHILD UNDER AGE OF 18 WHO IS NOT IDENTIFIED
AS A FOSTER CHILD]? Esta pregunta se refiere a sus propios ingresos y recursos para
apoyar a [NAME] financieramente, no los ingresos y recursos de los demás, sobre los que
preguntaremos después.
YES ............................................................................................ 1
NO .............................................................................................. 2

DISPLAY LIST OF ALL PERSONS ON HOUSEHOLD ROSTER AGE 18 AND OLDER.
E21.

Basado en la información que proporcionó sobre las personas que viven en su hogar, el
estudio considera que estas personas son adultos, es decir de 18 años de edad o mayor.
INTERVIEWER READ LIST.
¿Incluye mi lista a todas las personas que se consideran adultos en este hogar?
YES ............................................................................................ 1

(GO TO BOX ED)

NO .............................................................................................. 2

(RETURN TO E8)

E22.

En octubre de 2017, ¿pagó [NAME OF EACH HOUSEHOLD MEMBER ON THE CREATED LIST
(REFERENCED IN BOX ABOVE)] algún gasto del hogar o proporcionó apoyo financiero a
[NAME OF CHILD UNDER 18 YEARS]?
YES ............................................................................................ 1
NO .............................................................................................. 2

E23.

En octubre de 2017, ¿pagó [NAME OF EACH HOUSEHOLD MEMBER ON THE CREATED
LIST] algún gasto del hogar o le proporcionó apoyo financiero a usted?
YES ............................................................................................ 1
NO .............................................................................................. 2

E24.

ASK E24 ONLY IF THE RELATIONSHIP TO THE RESPONDENT IS FOSTER CHILD
¿Quién tiene responsabilidad legal y financiera por [NAME OF FOSTER CHILD]?
SELECT NAME(S) FROM HOUSEHOLD ROSTER.................. 1
SOMEONE OUTSIDE THE HOUSEHOLD ................................ 2
AN AGENCY .............................................................................. 3
OTHER (SPECIFY) _________________________

SECTION END TIME: ________________

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: A continuación, me gustaría hacerle preguntas acerca de beneficios que puede
recibir su hogar a través de programas gubernamentales como SNAP o TANF. Pronto tendrá que mirar
alguna documentación que tiene sobre pagos de estos programas. ¿Tiene eso listo?
INTERVIEWER: IF NO, GIVE TIME FOR RESPONDENT TO COLLECT DOCUMENTATION WHENEVER
POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.
SNAP BENEFITS
Hablemos sobre cualquier beneficio [SNAP/STATE NAME FOR SNAP] que puede recibir su hogar. No
incluya beneficios [SNAP/STATE NAME FOR SNAP] que recibe otro miembro del hogar con su propio
número de caso [SNAP/STATE NAME FOR SNAP] que no le incluye a usted, su cónyuge y/o su hijo(s).
F1.

F2.

F3.

En octubre de 2017, ¿recibió usted, su cónyuge, y/o su hijo(s) beneficios del Programa de
Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés) (antes conocido
como Cupones para Alimentos), o beneficios [STATE NAME FOR SNAP]?
YES ............................................................................................ 1

(GO TO F3)

NO .............................................................................................. 2

(GO TO F2)

¿Recibió usted, su cónyuge y/o suhijo(s) beneficios SNAP o beneficios [STATE NAME FOR
SNAP] en algún momento del año escolar 2017-2018?
YES ............................................................................................ 1

(GO TO F3)

NO .............................................................................................. 2

(GO TO F7)

Necesitamos verificar que usted y su hijo(s)/usted y su cónyuge y su(s) hijo(s) recibieron
beneficios [SNAP/STATE NAME FOR SNAP] durante el año escolar 2017-2018. Podemos
obtener eso de su tarjeta EBT [SNAP/STATE NAME FOR SNAP], extracto de adjudicación o
notificación de pago. ¿Tiene una tarjeta EBT [SNAP/STATE NAME FOR SNAP], extracto de
adjudicación o notificación de pago que pueda mostrarme?
YES ............................................................................................ 1

(GO TO F4)

NO .............................................................................................. 2

(GO TO F7)

F4.

F5.

F6.

¿Recibe alguien más en su hogar [SNAP /State name for SNAP] con otro número de caso?
YES ............................................................................................ 1

(GO TO F6)

NO .............................................................................................. 2

(GO TO F7)

¿Comparte usted vivienda, ingresos o gastos de alimentación con esta persona?
YES ............................................................................................ 1

(GO TO F7)

NO .............................................................................................. 2

(GO TO F7)

TANF BENEFITS
Hablemos sobre beneficios TANF. No incluya beneficios TANF que recibe otro miembro del hogar con
su propio número de caso TANF que no le incluye a usted, su cónyuge y/o su(s) hijo(s).
F7.

F8.

F9.

En octubre de 2017, ¿recibió usted, su cónyuge, y/o su hijo(s) beneficios del Programa de
Asistencia Temporal para Familias Necesitadas, también conocido como beneficios
sociales en efectivo, o [STATE NAME FOR TANF]?
YES ............................................................................................ 1

(GO TO F9)

NO .............................................................................................. 2

(GO TO F8)

¿Recibió usted, su cónyuge y/o su hijo(s) beneficios [TANF/STATE NAME FOR TANF] en
algún momento del año escolar 2017-2018?
YES ............................................................................................ 1

(GO TO F9)

NO .............................................................................................. 2

(GO TO F13)

Necesitamos verificar que usted y su hijo(s)/usted y su cónyuge y su(s) hijo(s) recibieron
beneficios [TANF/STATE NAME FOR TANF] durante el año escolar 2017-2018. Podemos
obtener eso de su tarjeta EBT [SNAP/STATE NAME FOR SNAP], extracto de adjudicación o
notificación de pago. ¿Tiene una tarjeta EBT [TANF/STATE NAME FOR TANF], extracto de
adjudicación o notificación de pago que pueda mostrarme?
YES ............................................................................................ 1

(GO TO F10)

NO .............................................................................................. 2

(GO TO F13)

F10.

F11.

F12.

¿Recibe alguien más en su hogar [TANF/STATE NAME FOR TANF] con otro número de
caso?
YES ............................................................................................ 1

(GO TO F12)

NO .............................................................................................. 2

(GO TO F13)

¿Comparte usted vivienda, ingresos o gastos de alimentación con esta persona?
YES ............................................................................................ 1

(GO TO F13)

NO .............................................................................................. 2

(GO TO F13)

OTHER BENEFITS
F13.

F14.

F15.

En octubre de 2017, ¿recibió usted, su cónyuge, y/o su hijo(s) beneficios del Programa de
Distribución de Alimentos en Reservaciones Indígenas (FDPIR, por sus siglas en inglés)?
No incluya beneficios FDPIR que recibe otro miembro del hogar con su propio número de
caso que no le incluye a usted, su cónyuge y/o su(s) hijo(s).
YES ............................................................................................ 1

(GO TO F15)

NO .............................................................................................. 2

(GO TO F14)

¿Recibió usted, su cónyuge y/o su(s) hijo(s) beneficios FDPIR en algún momento del año
escolar 2017-2018?
YES ............................................................................................ 1

(GO TO F15)

NO .............................................................................................. 2

(GO TO G1)

Necesitamos verificar que usted y su hijo(s)/usted y su cónyuge y su(s) hijo(s) recibieron
beneficios FDPIR durante el año escolar 2017-2018. Podemos obtener eso de su tarjeta EBT
FDPIR, extracto de adjudicación o notificación de pago. ¿Tiene una tarjeta EBT FDPIR,
extracto de adjudicación o notificación de pago que pueda mostrarme?
YES ............................................................................................ 1

(GO TO F16)

NO .............................................................................................. 2

(GO TO G1)

F16.

SECTION END TIME: ________________

SECTION G: INCOME AND EARNING SOURCES

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

Ahora le preguntamos sobre fuentes de ingreso y beneficios que pueden tener usted y su hogar
cada mes. Aunque estas preguntas pueden parecer personales, son importantes para comprender
el proceso de solicitud para comidas escolares y las necesidades de las familias que tienen hijos
matriculados en el distrito escolar [TARGET SCHOOL DISTRICT NAME]. Queremos asegurarle que
todas sus respuestas se mantienen de manera estrictamente privada.
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.

En octubre de 2017, ¿tuvo ([TARGET STUDENT NAME]/CHILD’S NAME]) algún ingreso del
Seguro Social (incluyendo Pagos por Incapacidad o Beneficios para Sobrevivientes),
personas fuera del hogar o alguna otra fuente? Esto es ingreso que se paga directamente
a su hijo(a), no ingreso que cobra usted mismo(a).
No incluya SNAP/State name for SNAP.

G2.

YES ............................................................................................ 1

(GO TO G2)

NO .............................................................................................. 2

(GO TO BOX GB)

¿Cuál fue la fuente de ese ingreso? SELECT ALL THAT APPLY
PROBE:¿Había alguna otra fuente de ingreso?
INTERVIEWER: IF THE RESPONDENT MENTIONS CHILD SUPPORT, SAY: El gobierno considera
la manutención de niños como ingreso para el adulto que cuida al niño, en vez de ingreso para
el propio niño. Le preguntaré sobre cualquier manutención de niño s en breve cuando pregunte
sobre el ingreso que cobra usted mismo(a).
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)

G3.

¿Cuánto se recibe mensualmente en beneficios del Seguro Social o beneficios por
incapacidad para sobrevivientes?
$ |___|,|___|___|___|

G4.

¿Cuánto se recibe mensualmente de personas fuera del hogar?
$ |___|,|___|___|___|

G5.

¿Cuánto se recibe mensualmente de las otras fuentes?
$ |___|,|___|___|___|

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.
Por favor consulte la tarjetamientras hablamos de las próximas preguntas.
ASK G6 FOR EACH ADULT (16+) CREATED IN BOX GB.
G6.

Revisemos cada fuente de ingreso. ¿Recibió ingreso de [SOURCE 1] por trabajo pago?
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 #
Source 1

TYPE OF INCOME OR BENEFITS PAYMENT
Ingreso por trabajo pago
Si tiene su propio negocio, solo incluya el sueldo que cobra como ingreso
personal o ganancias regulares. No incluya las ganancias o pérdidas del negocio.
No incluya ganancias infrecuentes, como ingreso ocasional por cuidar niños o
cortar el césped. Para miembros del servicio militar, incluya Pago Básico Militar.
Para miembros del servicio desplegados, solo incluya el monto ganado
disponible para el hogar.

Source 2

Compensación por Desempleo
Ingresos que reemplazan ganancias o sueldo, pagados a trabajadores
recientemente desempleados bajo un programa administrado por un gobierno o
sindicato.

Source 3

Beneficios de Compensación de Trabajadores
Pago obligatorio por ley a un empleado que está lesionado o incapacitado en
conección con el trabajo.

Source 4

Beneficios de Huelga
Dinero pagado a huelguistas por un sindicato para posibilitarles ser apoyados
durante una huelga.

Source 5

Jubilación del Seguro Social o Retiro Ferroviario
El programa de retiro ferroviario proporciona beneficios de jubilación,
desempleo de sobrevivientes y beneficios por enfermedad a individuos que han
dedicado una parte significativa de su carrera al empleo ferroviario, al igual que
a las familias de los trabajadores.
La jubilación del Seguro Social es un programa de seguro federal que
proporciona beneficios a personas jubiladas y a aquellos que están
desempleados o incapacitados.

Source 6

Pensiones (públicas o privadas), Anualidades o Beneficios para
Sobrevivientes
Una pensión es un fondo al que se agrega una suma de dinero durante los años
de trabajo de un empleado, y del cual se retiran pagos para apoyar la jubilación
de la persona del trabajo en la forma de pagos periódicos.
Una anualidad es un contrato entre usted y una empresa de seguros que
requiere que el asegurador le haga pagos a usted, ya sea inmediatamente o en
el futuro. Usted compra una anualidad efectuando un pago único o una serie de
pagos. Asimismo, su pago puede ser un pago único o una serie de pagos a lo
largo del tiempo.
Beneficios para Sobrevivientes son para viudas y viudos recibiendo
beneficios mensuales del Seguro Social basados en los registros de ganancias
de su cónyuge fallecido.

SOURCE #
Source 7

TYPE OF INCOME OR BENEFITS PAYMENT
Beneficios Militares en Efectivo
Beneficios en efectivo para subsidios de vivienda, comida, o ropa, incluyendo el
Subsidio Básico para Vivienda (BAH, por sus siglas en inglés). No incluya pago
de combate, o beneficios del Subsidio Suplementario para la Subsistencia
Familiar (FSSA, por sus siglas en inglés) o la Iniciativa de Privatización de la
Vivienda Militar (MHPI, por sus siglas en inglés). Para miembros del servicio
desplegados, solo incluya el monto a disposición del hogar.

Source 8

Beneficios de Veteranos
Beneficios que recibe basados en servicio militar.

Source 9

Beneficios del Gobierno por Incapacidad de la Seguridad de Ingreso
Suplementario (SSI, por sus siglas en inglés)
El programa SSI paga beneficios a adults y niños incapacitados que tienen
ingresos y recursos limitados.

Source 10

Beneficios Privados por Incapacidad
Proporciona beneficios a empleados que no pueden trabajar por incapacidad,
pagando todos o parte de sus sueldos de una póliza de seguros que puede
provenir de un empleador como beneficio para empleados, o de una póliza de
seguros que puede ser comprada por un individuo directamente de una
empresa de seguros.

Source 11

Pagos de Pensión Alimenticia
Pagos efectuados como pago único o de manera continua para proporcionar
apoyo financiero a un cónyuge antes de o después de una separación
matrimonial o divorcio. Pensión alimenticia NO incluye manutención de niños,
acuerdos de distribución de bienes distintos del efectivo, pagos para mantener
los bienes del pagador o el uso de los bienes del pagador.

Source 12

Pagos de Manutención de Niños
Pagos continuos efectuados por un padre para contribuir a los costos de criar a
su hijo(a) tras el fin de un matrimonio u otra relación.

Source 13

Ingresos por Intereses y Dividendos
Un dividendo es una distribución de una porción de las ganancias de una
empresa, decidido por la junta directiva, a una clase de sus accionistas. Los
dividendos pueden ser expedidos como pagos en efectivo, acciones u otros
bienes.
Interés ganado de inversiones es ingreso por intereses.

Source 14

Ingresos Netos de Alquiler
El monto que alguien le paga por usar su propiedad, después de restar los
gastos que tiene por la propiedad.

Source 15

Ganancias o Pérdidas del Negocio No Agrícola, Sociedad o Consultorio
Profesional
Estos son ganancias o pérdidas que no están incluidas en el sueldo que usted
se paga a si mismo(a) como ingreso personal o ganancias regulares.

SOURCE #
Source 16

TYPE OF INCOME OR BENEFITS PAYMENT
Ganancias o Pérdidas de una Granja
Ingreso ganado o perdido al cultivar cosechas, criar ganado, criar peces u
operar un rancho.

Source 17

Ayuda Financiera para Estudiantes Universitarios
Incluya dinero usado para vivienda y comida, pero excluya dinero usado para
matrícula, libros y tarifas, incluyendo Becas Pell, Becas Suplementarias para la
Oportunidad Educativa, Becas Estatales de Incentiva para Estudiante,
Préstamos Nacionales Directos al Estudiante, PLUS, Programas Universitarios
de Trabajo y Estudio o Programas de Becas de Honor Byrd.

Source 18

Pagos Regulares o Retiros de Grandes Premios o Acuerdos
Incluya ingreso de acuerdos legales, herencia, premios ganados o bonos.

Source 19

Contribuciones Regulares de Personas Fuera del Hogar
Incluya regalos en efectivo u otra asistencia financiera de amigos o familiares.

Source 20

Otros Ingresos, como Regalías Netas, Ingreso por Fideicomiso, o 401K.

Source 21

Beneficios de Asistencia General
Programas estatales o del condado que sirven a personas de bajos ingresos que
no tienen hijos menores, no están suficientemente incapacitadas para calificar
para (o aún no reciben) Seguridad de Ingreso Suplementario (SSI, por sus siglas
en inglés) y no son ancianos.

Source 22

Subsidio de Vivienda (no incluya subsidios Federales de vivienda)
Vivienda subvencionada es propiedad y es operada por dueños privados que
reciben subsidios a cambio de alquilar a personas de bajos y moderados
ingresos. Los dueños pueden ser propietarios individuales o corporaciones con
fines de lucro o sin fines de lucro. Esto no incluye programas de vivienda
subvencionada dirigidos por el Departamento de Vivienda y Desarrollo Urbano
de los Estados Unidos (HUD, por sus siglas en inglés) como Sección 8 o el
programa de Asistencia de Alquiler Rural dirigido por el USDA.

Source 23

Programa Federal del Pulmón Negro
Proporciona compensación a mineros del carbón que están completamente
incapacitados por neumoconiosis debido al empleo en minas de carbón, y a los
sobrevivientes de mineros del carbón cuyas muertes se pueden atribuir a la
enfermedad y proporciona cobertura médica a mineros elegibles para tratar
enfermedades pulmonares relacionadas a la neumoconiosis.

Source 24

Otros Beneficios Públicos, sin incluir TANF/[STATE NAME for TANF] o SNAP/
[STATE NAME for SNAP]
Otros beneficios como Mujeres, Infantes y Niños (WIC, por sus siglas en inglés)
o Programa Estatal de Seguro Médico para Niños (SCHIP, por sus siglas en
inglés). No incluya beneficios TANF/[STATE NAME for TANF] o SNAP/ [STATE
NAME for SNAP].

Source 25

Seleccionar si la persona no tiene ninguna fuente de ingreso o beneficios.

IF RESPONDENT REPORTS NO INCOME FROM PAID WORK AT G6
G7.

G8.

¿Ha hecho algún trabajo pago en algún momento del año escolar 2017-2018? Por favor
incluya trabajos pagos regulares, trabajos esporádicos, trabajos temporales, trabajo en su
propio negocio, trabajo “en negro”, trabajo “informal” o cualquier otro tipo de trabajo que
ha hecho.
YES ............................................................................................ 1

(GO TO G8)

NO .............................................................................................. 2

(GO TO G8)

DON’T KNOW ............................................................................ d

(GO TO G8)

REFUSED ................................................................................... r

(GO TO G8)

¿En qué mes y año hizo trabajo pago la última vez? Por favor incluya trabajos pagos
regulares, trabajos esporádicos, trabajos temporales, trabajo en su propio negocio, trabajo
“en negro”, trabajo “informal” o cualquier otro tipo de trabajo que ha hecho.
| | | | | | | |
MONTH
YEAR
(1-12)
(1930-2018)
NEVER WORKED FOR PAY ..................................................... 1
DON’T KNOW ............................................................................ d
REFUSED ................................................................................... r

G9.

Ahora le voy a leer una lista de cosas que pueden dificultar que las personas encuentren o
mantengan un trabajo. Por favor consulte la tarjeta paral contestar estas preguntas.
Por favor dígame si cada una de las siguientes cosas ha hecho que le sea para nada difícil,
un poco difícil, bastante difícil, muy difícil o extremadamente difícil encontrar o mantener
un trabajo durante el año pasado.
HAND SHOWCARD #7 TO RESPONDENT
CODE ONE PER ROW
NOT AT
A
ALL
LITTLE
HARD
HARD

SOMEWHAT
HARD

VERY
HARD

EXTREMELY
HARD

DON’T
KNOW

REFUSED

a. Problemas para llegar al
trabajo, como no tener
auto o acceso a
transportes públicos. .........

b. No tener los tipos de
habilidades que buscan los
empleadores.. ......................

c. Tener que cuidar a un
miembro de la familia. ........

d. No tener un lugar estable
para vivir. .............................

e. Consumo de alcohol o
drogas.. ................................

f. Problemas para llevarse
bien con otras personas o
controlar su enojo. .............

g. Su salud física... ..................

h. Tener antecedentes
criminales. ...........................

i. Otra (especifique). ..............

SECTION END TIME: ________________

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.
A continuación, me gustaría preguntarle sobre los distintos montos de ingreso que recibió usted y los
otros adultos en su hogar de las fuentes que acaba de mencionar. Para cada tipo de ingreso que declaró,
vamos a revisar el ingreso y mirar los documentos juntos para asegurarnos que tenemos las cantidades
correctas. Podemos tomar un breve descanso ahora para que pueda buscar la documentación. Los tipos
de documentos que me gustaría ver son talones de cheque, talones de pago o la declaración de impuestos
del año pasado para ganancias de trabajos, recibos por trabajos pagados en efectivo, declaraciones de
licencia y ganancias, registros comerciales, cartas de adjudicación, o resúmenes de estados de cuenta
que acompañan pagos de pensiones o beneficios.
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.
Me acaba de decir que (usted/[PERSON’S NAME]) tuvo ingresos de trabajos pagos en octubre de 2017.
Trabajemos juntos, usando la documentación que tiene disponible, para documentar el ingreso total
que recibió (usted/[PERSON’S NAME]) la última vez que le pagaron.
INTERVIEWER: WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY
RESPONDENT’S RESPONSES.
H1.

Necesitamos anotar el monto de ingresos de (usted/[PERSON’S NAME]) de todos los
trabajos pagos en octubre de 2017. El monto que necesito es el ingreso bruto, antes de
impuestos y otras deducciones que fue el total pagado a (usted/[PERSON’S NAME]), no la
cantidad que llevó a casa.
Por favor incluya sueldo, salarios, propinas, comisiones, bonos en efectivo, y pago por horas
extras regulares.
Por favor no incluya ganancias o pérdidas del negocio agrícola o no agrícola, sociedad o
consultorio profesional de (usted/[PERSON’S NAME]) en octubre de 2017.
¿Cuánto ganó (usted/[PERSON’S NAME]) de un trabajo pago en octubre de 2017?
IF APPROPRIATE, ADD: Probablemente podemos obtener ese monto de la declaración de
ingresos.
IF NEEDED, ADD:¿Tiene una declaración de ingresos de octubre de 2017?
IF DOCUMENTATION IS NOT AVAILABLE, ADD: Su mejor estimación está bien.
$ |___|___|,|___|___|___|

H2.

¿Con qué frecuencia se le pagan a (usted/[PERSON’S NAME]) estos ingresos?
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) _________________________

(GO TO H4)

ASK IF H2 = DON’T KNOW
H3.

Necesitamos anotar la cantidad de veces que (usted/[PERSON’S NAME]) fue pagado en
octubre de 2017. IF APPROPRIATE, ADD: Podemos mirar la declaración de ingresos para
obtener esta información. Su mejor estimación está bien.
INTERVIEWER: IF RESPONDENT ANSWERS DON’T KNOW, A COMMENT MUST BE
ENTERED FOR CLARIFICATION.
|___|___|
TIMES PAID

H4.

H5.

(GO TO H11)

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.

(GO TO H11)

¿Es la cantidad que acabamos de discutir como el ingreso de (usted/[PERSON’S NAME]) de
este trabajo pago aproximadamente igual a, menos que, o más que el ingreso de su hogar
en octubre de 2017?
IF NEEDED, ADD: Le estoy pidiendo que compare el monto de su ingreso en este talón de
pago con el ingreso de este trabajo que se declaró cuando se determinó la elegibilidad de
[TARGET STUDENT NAME] para beneficios del programa de comidas escolares en
[TARGET SCHOOL].
ABOUT THE SAME .................................................................... 1

(GO TO H11)

LESS .......................................................................................... 2
MORE ......................................................................................... 3
H10.

¿Cuál es su mejor estimación del monto que recibió (usted/[PERSON’S NAME]) de este
trabajo pago en octubre de 2017?
$ |___|___|,|___|___|___|

H11.

¿Tuvo (usted/[PERSON’S NAME]) algún otro trabajo pago en octubre de 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.
ASK H12-H20 ABOUT EVERY OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT (16+)
PERSON BEFORE CONTINUING TO ASK THE SAME SERIES FOR THE NEXT ADULT.
Antes me contó de algunas otras fuentes de ingreso que reibieron usted y otras personas en su hogar
en octubre de 2017. Nuevamente, trabajemos juntos usando la información que tiene disponible, para
mostrar las cantidades que recibió (usted/[PERSON’S NAME]) de estas otras fuentes.
INTERVIEWER: WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY
RESPONDENT’S RESPONSES.
H12.

¿Cuánto ingreso recibió (usted/[PERSON’S NAME]) de [SOURCE IN G8], en octubre de
2017?
IF APPROPRIATE, ADD: Probablemente podemos obtener ese monto de la declaración de
pagos. ¿Tiene una declaración de beneficios de octubre de 2017?
OR ADD: Su mejor estimación está bien.
$ |___|___|,|___|___|___|

H13.

¿Con qué frecuencia recibió (usted/[PERSON’S NAME]) [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) _________________________

H14.

(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) _________________________

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 ....................................................................... 6
ASK IF H18 DOES NOT = 1
H19.

¿Es esta cantidad que acabamos de discutir como el pago de (usted/[PERSON’S NAME]) de
esta fuente aproximadamente igual a, menos que, o más que el pago que recibió en octubre
de 2017?
IF NEEDED, ADD: Le estoy pidiendo que compare el pago en esta declaración con el pago
de [OTHER INCOME SOURCE] declarado cuando se verificó la elegibilidad de [TARGET
STUDENT NAME] para beneficios del programa de comidas escolares en [TARGET School].
ABOUT THE SAME .................................................................... 1

(GO TO BOX HD)

LESS .......................................................................................... 2
MORE ......................................................................................... 3
H20.

¿Cuál es su mejor estimación del monto que recibió (usted/[PERSON’S NAME]) de [OTHER
INCOME SOURCE] en octubre de 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 END TIME: ________________

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.

La computadora acaba de sumar todas las fuentes de ingreso que me contó y el ingreso
total del hogar para todos los miembros del hogar en octubre de 2017 (incluyendo el ingreso
de las personas que ya no están aquí) es [CALCULATED TOTAL FROM ALL SOURCES].
¿Eso le parece correcto?
YES ............................................................................................ 1

(GO TO I4)

NO .............................................................................................. 2

(GO TO I2)

ASK IF CALCULATED TOTAL DOES NOT SEEM ACCURATE.
I2.

Ya que cree que el total calculado por la computadora es incorrecto, revisemos cada fuente
que me contó para corregir los montos.
INTERVIEWER: READ RESPONDENT EACH INCOME SOURCE AND AMOUNT AND MAKE
ADJUSTMENTS WHERE NEEDED. WHEN REVIEW IS COMPLETE, CODE 1 TO CONTINUE.
CONTINUE ................................................................................. 1

I3.

El ingreso total corregido para [MONTH] ahora es [TOTAL FROM ALL SOURCES LISTED IN
SECTION F and G]. ¿Eso le parece correcto?
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.

¿Son los [TOTAL FROM ALL SOURCES LISTED IN SECTION F and G] que acabamos de
anotar para su hogar en [MONTH] una cantidad usual, o fue más o menos que el ingreso
promedio mensual que espera tendría (usted/él/ella) durante este año escolar?
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.

Ya que el monto total que acabamos de anotar para su hogar en [MONTH] no es la cantidad
usual, ¿cuánto espera que sea el monto usual de ingreso mensual de su hogar durante el
año escolar?
$ |___|___|___|,|___|___|___|

SECTION J: DEMOGRAPHIC CHARACTERISTICS

Section J is a series of demographic questions about the respondent and target student.
El próximo grupo de preguntas nos ayudará a obtener información de antecedentes de las personas
que completan esta encuesta.

ASK EVERYONE
J1.

¿Está actualmente casado(a), viviendo con una pareja con quien no está casado(a),
viudo(a), divorciado(a), separado(a) o nunca se casó?
MARRIED ................................................................................... 1
LIVING WITH PARTNER TO WHOM YOU ARE NOT
MARRIED ................................................................................... 2
WIDOWED ................................................................................. 3
DIVORCED................................................................................. 4
SEPARATED .............................................................................. 5
SINGLE AND NEVER MARRIED............................................... 6

J2.

¿Cuál es el grado o nivel de educación más alto que ha completado?
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) _________________________

J3.

¿Se considera de origen hispano o latino?
PROBE:

¿Origen cubano, mexicano, puertorriqueño, sudamericano o centroamericano o
de otra cultura u origen español?
YES ............................................................................................ 1
NO .............................................................................................. 2

J4.

¿Es usted Indígena Americano(a) o Nativo(a) de Alaska, Asiático(a), Negro(a) o
Afroamericano(a), Nativo(a) de Hawái o de Otra Isla del Pacífico, o Blanco(a)? 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
OTHER (SPECIFY) ................................................................... 6
REFUSED ................................................................................... r

J5.

¿Es inglés el idioma principal que se habla en este hogar?
YES ............................................................................................ 1
NO .............................................................................................. 2

J6.

¿Cuál es el idioma principal que se habla en el hogar?
Spanish ....................................................................................... 2
Chinese (e.g. Mandarin or Cantonese) ...................................... 3
French ........................................................................................ 4
Tagalog ....................................................................................... 5
Vietnamese................................................................................. 6
Korean ........................................................................................ 7
Arabic ......................................................................................... 8
Russian ....................................................................................... 9
OTHER (SPECIFY) _________________________

J7.

¿Es usted ciudadano(a) de los Estados Unidos?
YES ............................................................................................ 1
NO .............................................................................................. 2

(GO TO J7)

J8.

¿Por cuánto tiempo ha vivido en los Estados Unidos?
MY ENTIRE LIFE ....................................................................... 1
OR
SINCE |___|___|___|___| ........................................................... 2
YEAR
OR
IF NEEDED: Incluya el número total de años/meses viviendos en los Estados Unidos.
|___|___| OR |___|___| ............................................................. 3
YEARS

MONTHS

Las siguientes preguntas son acerca de [TARGET STUDENT NAME].
J9.

¿Es [TARGET STUDENT NAME] de origen hispano o latino?
PROBE:¿Origen cubano, mexicano, puertorriqueño, sudamericano o centroamericano o de
otra cultura u origen español?
YES ............................................................................................ 1
NO .............................................................................................. 2

J10.

¿Es (él/ella) Nativo(a) Americano(a) o Nativo(a) de Alaska, Asiático(a), Negro(a) o
Afroamericano(a), Nativo(a) de Hawái o de Otra Isla del Pacífico, o Blanco(a)?
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
OTHER (SPECIFY) ___________________________

REFUSED .................................................................................. 7

SECTION END TIME: ________________

SECTION K: CONCLUSION

Section K concludes the household interview, thanks the respondent for participating, and provides
guidance for distributing a gift card.
Estas son todas las preguntas que tengo para usted. Antes de irme, me gustaría darle esta tarjeta
de regalo para agradecerle por participar en este importante estudio. Por favor firme aquí para
confirmar que ha completado la encuesta y recibido su regalo. Gracias.

SURVEY END TIME: ________________

File Type	application/pdf
Author	RsuttonHeisey
File Modified	2017-07-19
File Created	2017-03-23