Respondents Individual/Households (SNAP Participants)

Appendix E.1

Pre-SNAP Participant Survey

English

The Food and Nutrition Service, United States Department of Agriculture is conducting a study to understand grocery shopping and eating behaviors. The survey will help answer questions like these:

• Where do people buy certain foods?

• What types of foods are people buying and eating?

• How do people decide what foods to buy?

Your household has been selected at random to participate in this survey. As an invited participant, your household represents many other households similar to yours, so your answers are important. This survey should take about 20 minutes to complete.

The survey should be completed by the primary food shopper in your household. The primary food shopper is the person who does the grocery shopping most often. The survey includes questions about foods purchased and eaten by your household. By household, we mean people who live with you and with whom you purchase and prepare food.

• If you live alone, please answer all questions for yourself.

• If you live with others, but you purchase foods and prepare meals for yourself only, please answer all questions for yourself.

• If you live with others and you share food purchases and meal preparation with people in your household, please answer all questions for your household.

There are no right or wrong answers. If you are unsure of how to answer a question, please give the best answer you can. Please know that as required by law, your information will be kept private and will be included with those of other survey participants. The law prohibits us from giving anyone any information that may identify you or your household. If you decide not to take part, that will not affect any benefits or services received by you or anyone in your household.

Please write clearly and use a black or blue pen only.

P lease answer by filling in the circles completely like this:

n ot or or

I f you make a mistake, mark through it with an X like this:

t hen fill in and draw a circle around the correct one like this:

Please remember to answer questions on both the front and back of each page. After you are done, return the survey in the enclosed postage-paid envelope. After we receive your completed survey, we will send you $20 in cash as a token of our appreciation. If you need additional information, please call 1-XXX-XXX-XXXX or email us at XXXX.com.

Thank you.

SECTION A. SHOPPING FOR GROCERIES

When answering these questions, please think about your household. By household, we mean people who live with you and with whom you purchase and prepare food. If you purchase foods and prepare meals for yourself only, please answer only for yourself.

A1. Where do you buy most of the groceries for your household?

Store name: __________________________

A1a. Is the store above a … (CHECK ONLY ONE)

• Large chain grocery store or supermarket (such as Albertsons, Giant, Kroger, Publix, Safeway)

• Discount superstore (such as Kmart, Target, Walmart)

• Convenience store (such as 7-Eleven or a mini market)

• Dollar Store

• Warehouse club store (such as BJ’s, Costco, Sam’s Club)

• Ethnic market

• Natural or organic supermarket/local markets

• Small local store or corner store

• Farmers market/farm stands/co-op

• Home delivery service (such as FreshDirect, Peapod)

• Other, tell us where: ____________________

A2. Why do you shop for groceries at this store? (CHECK ALL THAT APPLY)

Close to home Close to work or school Location convenient but not close to home, work, or school Affordable prices Lots of in-store promotions Deals on fruits and vegetables Variety of products Ethnic foods are available High-quality meat Preferred products are always available

Better or fresher produce than other stores Good service Store is clean Store is familiar to me Convenient store hours Frequent shopper program or savings card Store accepts EBT Home delivery option Other, tell us why: ____________________

A3. How often do you usually shop for groceries?

• More than once a week

• Once a week

• Once every two weeks

• Once a month or less

• Rarely make any major shopping trips, only small trips

• Rarely shop for food

SECTION B. SHOPPING FOR FRUITS AND VEGETABLES

B1. Where do you usually buy fruits and vegetables for your household? (CHECK ONLY ONE)

• Large chain grocery store or supermarket (such as Albertsons, Giant, Kroger, Publix, Safeway)

• Discount superstore (such as Kmart, Target, Walmart)

• Convenience store (such as 7-Eleven or a mini market)

• Dollar Store

• Warehouse club store (such as BJ’s, Costco, Sam’s Club)

• Ethnic market

• Natural or organic supermarket/local markets

• Small local store or corner store

• Farmers market/farm stands/co-op

• Home delivery service (such as FreshDirect, Peapod)

• Other, tell us where: ____________________

B2. How often do you make special efforts to go to a particular store to buy fresh or high-quality fruits or vegetables?

• Always

• Most of the time

• Sometimes

• Rarely

• Never

B3. What is your household's usual MONTHLY expense for fruits and vegetables (include fresh, frozen, canned, and dried fruits and vegetables)?

$ |___|___|___|

• Don’t know

B4. In the past year, how many times did you shop for fruits and vegetables at farmers markets?

• Never  GO TO B5

• Less than once a month

• Once a month

• Every other week

• Once a week

• More than once a week

B4a. Some farmers markets provide a matching amount to <STATE NAME FOR SNAP/EBT card> customers when they buy fruits and vegetables using their <STATE NAME FOR SNAP/EBT CARD>. For example, the market may give $2 for every $5 spent using <STATE NAME FOR SNAP/EBT card>. Did you get any such matching amount at the farmers market where you shopped?

• Yes

• No

• Don’t know

B5. Some stores offer coupons, or discounts on fruit and vegetable purchases. In the past year, did you get any coupons or discounts when you shopped for fruits and vegetables?

• Yes

• No

• Don’t know

B6. In the past month, how often did you buy the following types of fruits and vegetables? For each type listed, put an X in the box that represents how often you bought it.

	More than once a week	Once a week	Every other week	Less than once a month	Never
Fresh fruits					
Frozen fruits					
Canned fruits					
Dried fruits					
100 percent fruit juice					
Fresh vegetables					
Frozen vegetables					
Canned vegetables					
Dried vegetables (e.g. mushrooms, dehydrated potatoes)					

B7. In the past month, when you bought fruits, what kind did you buy? For each type listed, put an X in the box that represents the type of fruit that you usually buy.

	Fresh	Frozen	Canned	Dried	I did not buy it
	CHECK ALL THAT APPLY
Bananas					
Apples					
Berries					
Oranges					
Melons					
Grapes					
Peaches					
Pineapples					
Pears					
Other: ________________________					
Other: ________________________					
Other: ________________________					

B8. In the past month, when you bought vegetables, what kind did you buy? For each type listed, put an X in the box that represents the type of vegetable that you usually buy.

	Fresh	Frozen	Canned	Dried	I did not buy it
	CHECK ALL THAT APPLY
Potatoes					
Lettuce/leafy salad greens					
Onions					
Tomatoes					
Carrots					
Green beans					
Peppers					
Legumes/shelled beans					
Broccoli					
Other: ________________________					
Other: ________________________					
Other: ________________________					

SECTION C. YOUR OPINIONS ABOUT FRUITS AND VEGETABLES

C1. For each statement listed, put an X in the box that best indicates how much you personally agree or disagree with that statement. If you don’t understand a statement or don’t have an opinion, select “Does not apply.”

	Strongly disagree	Somewhat Disagree	Neither disagree nor agree	Somewhat Agree	Strongly agree	Does not apply
I enjoy trying new foods						
I enjoy trying new fruits						
I enjoy trying new vegetables						
I eat enough fruits to keep me healthy						
I eat enough vegetables to keep me healthy						
I encourage my family to eat fruits and vegetables						
I encourage my friends to eat fruits and vegetables						

These questions are about the different kinds of fruits and vegetables you ate or drank during the LAST MONTH. Please think about all fruits, vegetables, and fruit juices that you had last month. Include those that were raw, cooked, eaten as snacks, and at meals; eaten at home and away from home in restaurants, with friends, and as take-out; and eaten alone and mixed with other foods.

C2. Over the past month, how many times per month, week, or day did you drink 100% juice such as orange, mango, apple, grape, or pineapple juices? Do not count fruit-flavored drinks with added sugar, like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight. Include juice you drank at all mealtimes and between meals.

Never GO TO C3

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C2a. Each time you drank 100% juice, how much did you usually drink?

Less than ¾ cup (less than 6 ounces)

¾ to 1 ¼ cup (6 to less than 10 ounces)

1 ¼ to 2 cups (10 to 16 ounces)

More than 2 cups (more than 16 ounces)

C3. Over the past month, how many times per month, week, or day did you eat fruit? Count any kind of fruit – fresh, canned, and frozen. Do not count juices. Include fruit you ate at all mealtimes and for snacks.

Never GO TO C4

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C3a. Each time you ate fruit, how much did you usually eat?

Less than 1 medium fruit	1 medium fruit	2 medium fruits	More than 2 medium fruits
OR
Less than ½ cup	About ½ cup	About 1 cup	More than 1 cup

C4. Over the past month, how many times per month, week, or day did you eat a lettuce or green leafy salad (with or without other vegetables)?

Never GO TO C5

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C4a. Each time you ate lettuce or green leafy salad, how much did you usually eat?

About ½ cup

About 1 cup

About 2 cups

More than 2 cups

C5. Over the past month, how many times per month, week, or day did you eat any kind of fried potatoes, including French fries, home fries, or hash brown potatoes?

Never GO TO C6

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C5a. Each time you ate fried potatoes, how much did you usually eat?

Small order or less (About 1 cup or less)

Medium order (About 1 ½ cups)

Large order (About 2 cups)

Super-size order or more (About 3 cups or more)

C6. Over the past month, how many times per month, week, or day did you eat other white potatoes? Count baked, boiled, and mashed potatoes, sweet potatoes, potato salad, and white potatoes that were not fried.

Never GO TO C7

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C6a. Each time you ate these potatoes, how much did you usually eat?

1 small potato or less (1/2 cup or less)

1 medium potato (½ to 1 cup)

1 large potato (1 to 1 ½ cups)

2 medium potatoes or more (1 ½ cups or more)

C7. Over the past month, how many times per month, week, or day did you eat cooked dried beans? Count refried beans, baked beans, beans in soup, pork and beans, or any other type of cooked dried beans?

Never GO TO C8

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C7a. Each time you ate these beans, how much did you usually eat?

Less than 1/2 cup

½ to 1 cup

1 to 1 ½ cups

More than 1 ½ cups

C8. Over the past month, how many times per month, week, or day, did you eat other vegetables? Count raw, cooked, canned, and frozen vegetables such as tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, plantains, yucca, chayote or other squash, and broccoli. DO NOT COUNT: lettuce salads; white potatoes; cooked dried beans; vegetables in mixtures such as in sandwiches, omelets, casseroles, Mexican dishes, stews, stir-fry, soups, etc.; and rice.

Never GO TO C9

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

2 times per day

3 times per day

4 times per day

5 or more times per day

C8a. Each time you ate these other vegetables, how much did you usually eat?

Less than 1/2 cup

½ to 1 cup

1 to 2 cups

More than 2 cups

C9. Over the past month, how many times per month, week, or day did you have tomato sauces such as spaghetti or noodles or mixed into foods such as lasagna? DO NOT COUNT: Tomato sauce on pizza.

Never GO TO C10

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C9a. Each time you ate tomato sauce, how much did you usually eat?

About ¼ cup

About ½ cup

About 1 cup

More than 1 cup

C10. Over the past month, how many times per month, week, or day did you have Mexican-type salsa made with tomato?

Never GO TO D1

1 to 3 times last month

1 to 2 times per week

3 to 4 times per week

5 to 6 times per week

1 time per day

2 times per day

3 times per day

4 times per day

5 or more times per day

C10a. Each time you ate salsa, how much did you usually eat?

Less than 1 tablespoon

1 to less than 3 tablespoons

to 5 tablespoons

More than 5 tablespoons

SECTION D. FOOD SITUATION IN YOUR HOUSEHOLD

These questions are about the food situation in your household in the last 30 days and whether you were able to afford the food you need. For each statement or question below, please select one response that best describes your household’s food situation.

D1. In the last 30 days, “we worried whether our food would run out before we got money to buy more.” Was that often, sometimes, or never true for your household?

• Often true

• Sometimes true

• Never true

• Don’t know

D2. In the last 30 days, “the food that we bought just didn’t last, and we didn’t have money to get more.” Was that often, sometimes, or never true for your household?

• Often true

• Sometimes true

• Never true

• Don’t know

D3. In the last 30 days, “we couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household?

• Often true

• Sometimes true

• Never true

• Don’t know

D4. In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?

• Y es

• No  GO TO D5

• Don’t know  GO TO D5

D4a. In the last 30 days, how often did this happen?

___ Days

D5. In the last 30 days, did you ever eat less than you felt you should because there wasn’t enough money for food?

• Yes

• No

• Don’t know

D6. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?

• Yes

• No

• Don’t know

D7. In the last 30 days, did you lose weight because there wasn’t enough money for food?

• Yes

• No

• Don’t know

D8. In the last 30 days, did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food?

• Y es

• No  GO TO D9

• Don’t know  GO TO D9

D8a. In the last 30 days, how often did this happen?

___ Days

D9. Over the last month, has your household had any unusually large expenses that affected your spending on food?

• Yes

• No

• Don’t know

SECTION E. YOU AND YOUR HOUSEHOLD

E1. Are you male or female?

• Male

• Female

E2. What is your marital status?

• Now married

• Widowed

• Divorced

• Separated

• Never married

E3. How old are you?

• 18-29 years old

• 30-39 years old

• 40-49 years old

• 50-59 years old

• 60 or older

E4. What language(s) do you usually speak at home? (CHECK ALL THAT APPLY)

• English

• Spanish

• Other, tell us which languages: _____________________________________

E5. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

E6. Which one or more of the following would you say is your race? (CHECK ALL THAT APPLY)

• American Indian or Alaska Native

• Asian

• Native Hawaiian Or Other Pacific Islander

• Black or African American

• White

E7. Were you born outside of the United States, Puerto Rico, or other U.S. territories?

• Yes

• No  GO TO F8

E7a. How long have you lived in the United States?

• Less than 1 year

• 1 year but less than 5 years

• 5 years but less than 10 years

• 10 years or more

E8. What is the highest grade or level of school you have completed or the highest degree you have received?

• Never attended school or only attended Kindergarten

• Less than high school

• High school diploma or GED

• Some college, no degree

• Associate degree: occupational, technical, or vocational program

• Associate degree: academic program

• Bachelor’s degree (example: BA, AB, BS, BBA)

• Master’s degree (example: MA, MS, MEng, MEd, MBA)

• Professional school degree (example: MD, DDS, DVM, JD)

• Doctoral degree (example: PhD, EdD)

E9. Which of the following were you doing last month? (CHECK ONLY ONE)

• With a job or business but not at work  GO TO E9a

• Not working at a job or business  GO TO E9a

• Working at a job or business  GO TO E10

• Looking for work  GO TO E10

E9a. What is the main reason you did not work last month?

• Taking care of house/family

• Going to school

• Retired

• Unable to work for health reasons

• Disabled

• On layoff/unemployed

• On vacation

• On strike

• Other, please specify: __________

E10. In general, would you say your health is…?

• Excellent

• Very good

• Good

• Fair

• Poor

E11. Thinking only about yourself, in general, how healthy is your overall diet?

• Excellent

• Very good

• Good

• Fair

• Poor

E12. In general, how healthy is your household’s overall diet?

• Excellent

• Very good

• Good

• Fair

• Poor

• Does not apply to me

E13. Including you, how many people currently live in your household? By household, we mean the people who share food and income with you. Please do not include people in your home who your SNAP/Food Stamp benefits and other income do not support.

|___|___| number of people who currently live in your household

E13a. How many of these are children 5-17 years old?

|___|___| number of children

E13b. How many of these are children under 5 years of age?

|___|___| number of children

E13c. How many are adults over 60 years?

|___|___| number of adults over 60

E14. In the last 12 months, has there been a change in the number of people living in your household?

• Yes  GO to F14a

• No  GO to F15

F14a. What caused the change? (CHECK ALL THAT APPLY)

• Birth of child

• New step, foster, or adopted child

• Marriage/New partner

• Separation or divorce

• Death of a household member

• Family/boarder moving in

• Family/boarder moving out

• Other, tell us what the change was: _____________________________________

E15. Do you or anyone who lives in your household get food from any of the following sources? (CHECK ALL THAT APPLY)

• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

• National School Lunch Program

• Senior Farmers Market Program

• Meals on Wheels

• Food Pantry

• Other, please specify: __________________________________

E16. Do you or anyone in your household currently get SNAP/Food Stamp benefits? This includes any SNAP or Food Stamp benefits, even if the amount is small and even if benefits are received on behalf of children in the household.

• Yes

• No

E17. Please indicate whether you or anyone in your household received income in the last 12 months from any of the following: (CHECK ALL THAT APPLY)

• Wages, salary, commissions, bonuses, or tips from all jobs

• Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships

• Interest, dividends, net rental income, royalty income, or income from estates and trusts

• Social Security or Railroad Retirement

• Supplemental Security Income (SSI)

• Any public assistance or welfare payments from the state or local welfare office

• Retirement, survivor, or disability pensions

• Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support or alimony

E18. What was the total income received last month by you and other household members before taxes? Please include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, and so forth).

$|___|___|___|___|

E19. Which category best describes your total household income last year, before taxes or other deductions?

• Under $10,000

• $10,000 - $19,000

• $20,000-$29,999

• $30,000-$39,999

• $40,000-$49,000

• Over $50,000

E20. Which of the following best describes your household’s current financial condition?

• Very comfortable and secure

• Able to make ends meet without much difficulty

• Occasionally have some difficulty making ends meet

• Tough to make ends meet but keeping your head above water

• In over your head

SECTION G. CONTACT INFORMATION

Please provide us with your contact information so we can send you $20 for completing the survey. We will not share your contact information with anyone.

First name: ____________________________________

Last name: ____________________________________

Street address: ________________________________

City: ________________________________________

State: ____________________

Zipcode: __________________

We would like to send you a follow-up survey within a year. Please provide us your contact information so we can follow-up with you:

Phone number: _______________________________

Cell phone number: ___________________________

Email: _____________________________________

Because phone numbers and email addresses can change over time, please tell us the name and contact information of 2 people who will know how to find you:

NAME:_____________________________ Street address: ______________________ ______________________ City, State, Zipcode: _________________ Phone: ____________________________ Cell phone: _________________________ Email: _____________________________

NAME:____________________________ Street address: ______________________ ______________________ City, State, Zipcode: _________________ Phone: ____________________________ Cell phone: _________________________ Email: _____________________________

Thank you for completing this survey.