Respondents- Individuals/Households (Parents/Children/Teens)

OMB Control No: 0584-XXXX

Expiration Date: 0X/XX/20XX

Appendix G7. Caregiver Survey

Summer Meals Survey

U.S. Department of Agriculture

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

Instructions for completing the survey

• Use black or blue ink to answer

• Write your answers in the space provided or Mark  to indicate your answer

• If you want to change your answer, mark and mark the right answer

• Follow the GO TO QUESTION instructions when specified

• There are no right or wrong answers. Your answers will help make the program better.

SECTION A. ABOUT THE CHILDREN IN YOUR HOUSEHOLD

A1. How many children ages 18 and younger are now living in your household?

|___|___| Total number of children ages 18 and under in your household

A2. How many children ages 18 and younger living in your household are:

|___|___| Less than five years of age

|___|___| Between 5 and 12 years of age

|___|___| Between 13 and 18 years of age

A3. Which of the following best describes where all children ages 18 and younger in your household spend their daytime in the summer months?

SELECT ONE OR MORE

At home with parent/guardian/sibling

At home with another relative

Home alone

At a relative’s/friend’s home

At a childcare/daycare home or center

At a summer camp or summer school

At a summer job

Other (please specify ____________________________________________________

A4. Thinking about all children ages 18 and younger in your household, how many went to or will go to a summer program that offers education and/or activities this summer, 2018?

None  GO TO QUESTION A6

|___|___| Number of children ages 18 and younger who went to or will go to a program

A5. Do these summer programs provide meals and/or snacks to children ages 18 and younger?

SELECT ONLY ONE

Yes, meals and snacks are available for purchase

Yes, meals and snacks are part of the program fee

Yes, free meals and snacks are provided

No, the programs do not provide meals or snacks

Not sure

A6. Have you heard of any programs in your area that offer free meals to children ages 18 and younger in the summer?

Yes

No

A7. Did you know that the program at <SITE NAME> at <ADDRESS> is offering free meals to children ages 18 and younger, this summer, 2018?

Yes

No

A8. Did, or have you planned to have, any of the children ages 18 and younger in your household go to the program at <SITE NAME> located at <address> this summer?

Yes

No  GO TO SECTION C

A9. When did you first find out about the summer program at <SITE NAME> located at <Address>?

This year

Last year

A few years ago

Not sure

A10. In what month this year, 2018, did you find out about the summer program at <SITE NAME>?

January February March April

May June July August (

A11. How did you find out about the summer program at <SITE NAME> this summer?

SELECT ONE OR MORE

Flyer or poster at child’s school

Flyer or poster at local government or public assistance office

Flyer or poster at local food bank

Flyer or poster at church or other community group

Television or radio

Poster or billboard on a bus stop/bus/train

Toll-free hotline

Internet or social media

Mail

Email or text message

Staff at child’s school told me about it

My child told me about it

My relative told me about it

My friend or neighbor told me about it

U.S. Department of Agriculture, Food and Nutrition Service (FNS) Site Finder

This survey

Other (please specify):

A12. Did the summer 2018 program materials you received about <SITE NAME> include information about …?

SELECT ONE OR MORE

Free meals

Program schedule (dates and times for the program)

Program Location/address

Program contact information

Types of activities offered

Program activity fee

How to apply

Transportation options

Child safety

Other (please specify):

Did not receive any program materials  GO QUESTION A14

A13. Did the information about the program include all the details you needed to make a decision about sending your child to the program at <SITE NAME> this summer?

Yes  GO TO SECTION B

No

A14. Did you contact the program staff at <SITE NAME> to get information about …

SELECT ONE OR MORE

Free meals

Program schedule (dates and times for the program)

Program Location/address

Program contact information

Types of activities offered

Cost to attend program (excluding meals)

How to apply

Transportation options

Child safety

Other (please specify):

SECTION B. YOUR EXPERIENCE WITH THE SUMMER PROGRAM AT <SITE NAME> LOCATED AT <ADDRESS> THIS SUMMER

Answer the following questions for a child who went to the program at <SITE NAME> at <ADDRESS> this summer.

B1. How many children ages 18 and younger in your household went or will go to the program at <SITE NAME> this summer, 2018?

|___|___| Number of children.

If more than one child in your household went to the program at <SITE NAME>, please answer the questions for the child who had the most recent birthday. We do not mean the youngest child, just the child who had the last birthday.

B2. How old is this child?

|___|___| Age of child who went to the program at <SITE NAME>

B3. Is this child a boy or a girl?

Boy

Girl

B4. What is your relationship to this child?

Parent (biological, adoptive, or foster)

Grandparent

Sibling

Other (please specify):

B5. Is this child Hispanic or Latino?

Yes, Hispanic or Latino

No, Not Hispanic or Latino

B6. What is the race of this child?

SELECT ONE OR MORE

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

B7. Besides going to the summer program at <SITE NAME>, did or will this child go to any other programs that offer education, activities, and/or food this summer?

Yes

No  GO TO QUESTION B9

Not sure  GO TO QUESTION B9

B8. Do these other summer programs provide meals or snacks to children ages 18 and younger?

SELECT ONLY ONE

Yes, meals and snacks are available for purchase

Yes, meals and snacks are part of the program fee

Yes, free meals and snacks are provided

No, the programs do not provide meals or snacks

Not sure

B9. FOR SCHOOL BASED SITE ONLY: Does your child go to <THIS SCHOOL> during the school year?

Yes

No

B10. Besides going to the program at <SITE NAME>, does/will this child get summer meals at the school they go to during the school year?

Yes

No

Don’t know

B11. Who was involved in making the decision for this child to go to the program at <SITE NAME> this summer?

SELECT ONE OR MORE

Parent (biological, adoptive, or foster)

Grandparent

Sibling

Other (please specify):

B12. Is 2018 the first summer this child went to or will go to the summer program at <SITE NAME>?

Yes, first time child went to this program

No, child went to this program in previous years

B13. Has this child already gone to the program at <SITE NAME> this summer, 2018?

Yes

No, will start going later this summer

B14. What are the main reasons for deciding to send this child to the program at <SITE NAME> this summer?

SELECT ONE OR MORE

Childcare is provided

Meals are free

Hours fit my schedule

Free transportation is provided

Good location

Games and activities are provided

My child does not want to stay home

My child’s friends go there

My child can make new friends there

Proof of income is not required

Other reasons (please specify):

B15. About how far from your home is the program at <SITE NAME>?

Less than 1 mile

Between 1 mile and 3 miles

More than 3 miles but fewer than 5 miles

Between 5 miles and 10 miles

More than 10 miles

B16. How did or will this child usually travel to and from the program at <SITE NAME> this summer?

SELECT ONLY ONE

Walk

Bike

Family vehicle

Program provides transportation

Public transportation

Other (please specify):

B17. Other than the way this child usually travels to and from the program at <SITE NAME>, which of the following options are also available to the child to get to and from the program at <SITE NAME> this summer?

SELECT ONE OR MORE

Walk

Bike

Family vehicle

Program provides transportation

Public transportation

Other (please specify):

No other option

B18. Thinking about how often this child went to or will go to the program at <SITE NAME> this summer, would you say that this child …

Went to or will go to the program as often as you desired

Went to or will go to the program less often than you desired

B19. Did/will this child go to the program at <SITE NAME> every week the program is offered this summer?

Yes

No

Don’t know/ not sure

B20. How many weeks did or will this child go to the program at <SITE NAME> this summer?

|___|___| Number of weeks child went to or will go to <SITE NAME> this summer

B21. About how many days a week did or will this child usually go to the program at <SITE NAME> this summer?

Once a week

2 days each week

3 days each week

4 days each week

5 or more days each week

B22. Thinking about how often this child went to or will go to the program at <SITE NAME> this summer, would you say that the number of days this child went to the program …

Was or will be about the same each week

Varied or will vary from week to week

B23. Why did or will this child not go to the program at <SITE NAME> for all weeks that the program was/is offered this summer?

SELECT ONE OR MORE

My child went to or will go to the program every week the program was/is offered

Visiting relatives/friends

At other summer programs

Others might think our family cannot provide meals/snacks for our child

Only needy families should send children to the program every week

Friends not going to the program

Not enough activities to keep the child happy

Prefer to be home some days/weeks

The location was not safe

Did not want to stay at the site to eat the meal

There was no shelter from the heat or rain

Do not like food served at the program

Do not like times when meals are provided

Other (please specify):

B24. Which of the following features would improve how often this child goes to the program at <SITE NAME>?

SELECT ONE OR MORE

Games and activities

Number of weeks the program is offered

Number of days each week the program is offered

Daily schedule (number of hours)

Walkable distance from home

Cost of program (not including meals and/or snacks)

Being able to take the meals home or to another place away from the site

Safe location

Shelter from heat and rain

Staff supervision

Having friends of child going to the program

Free transportation

Other (please specify):

None of the above

Does not apply to me, my child goes to the program every day

B25. On days that this child went to the program at <SITE NAME> this summer, how often did this child eat meals and/or snacks provided by the program?

SELECT ONLY ONE

Every day the child went GO TO QUESTION B27

Most days the child went

Some days the child went

Never

Don’t know

Child has not yet gone to the program at <SITE NAME> this summer  GO TO SECTION D

B26. What would have encouraged this child to eat the meals and/or snacks provided by <SITE NAME> on all days that the child went there, this summer?

SELECT ONE OR MORE

If <MEAL NOT SERVED> was provided

If child could bring meals and/or snacks home

Better looking food

Better tasting food

Larger amount of food

Information about what foods will be provided

More hot meals

More variety of food

Healthier food

Information on the nutrition content of foods

More time to eat

Shelter from heat and rain

Safe location

Shorter lines

Being able to take the meals home or to another place away from the site Meals for parents/caregivers

No change is needed; I am satisfied with the meals/snacks

I don’t know enough about the meals and/or snacks to answer this question

B27. In general, how would you rate the appearance of meals and/or snacks served by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the meals and/or snacks provided by the program

B28. In general, how would you rate the variety of foods served at meals and/or by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the meals and/or snacks provided by the program

B29. Overall, how satisfied or dissatisfied are you with the meals and/or snacks provided by the program at <SITE NAME> this summer?

Very Satisfied

Satisfied

Neither satisfied or dissatisfied

Dissatisfied

Very dissatisfied

I don’t know enough about the meals and/or snacks provided by the program

B30. Thinking about your experience with the program at <SITE NAME>, how satisfied or dissatisfied are you with the program this summer?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very Dissatisfied

B31. How likely is it that you would recommend the program at <SITE NAME> to other families with children?

Very likely

Somewhat likely

Not at all likely

B32. Is there anything else you would like to tell us about the summer meals site where this child receives meals this summer?

GO TO SECTION D

SECTION C. PRIOR EXPERIENCE WITH THE SUMMER MEALS PROGRAM AND REASONS FOR NOT SENDING YOUR CHILDREN TO A SUMMER MEALS PROGRAM THIS SUMMER

C1. Did any of the children in your household ever go to a program that offered education and/or activities along with free meals, or a program that offers just free meals to children ages 18 and younger?

Yes

No  GO TO QUESTION C8

C2. Thinking about all children ages 18 and younger in your household, how many children ever went to a summer program that offered education and/or activities along with free meals or a program that offered just free meals?

|___|___| Number of children ages 18 and younger

C3. How old were these children when they attended a program that offered education and/or activities along with free meals or a program that offers just free meals?

SELECT ONE OR MORE

0 to 4 years

5 to 12 years

13 to 18 years

C4. Overall, how satisfied or dissatisfied were you with the program?

Very Satisfied

Satisfied

Neither satisfied or dissatisfied

Dissatisfied

Very dissatisfied

C5. How likely is it that you would recommend the program to other families with children?

Very likely

Somewhat likely

Not at all likely

C6. Why or why haven’t children in your household gone to the summer program at <SITE NAME> located at <ADDRESS> this summer? This summer program is the nearest place that offers free summer meals to children in your area.

SELECT ONE OR MORE

Did not know about the program at <SITE NAME>

Don’t think my children are eligible to receive free meals

Visiting relatives/friends

At other summer programs

Others might think our family cannot provide meals/snacks for our child

Only needy families should send children to the program every week

Friends not going to the program

Not enough activities to keep the child engaged

Prefer to be home some days/weeks

Do not like the meals and/or snacks

Do not like times when meals are provided

Meals could not be brought home

Meals not provided for parents/caregivers

Other (please specify):

C7 Which of the following features would have made it possible for children in your household to go to the summer program at <SITE NAME> this summer?

SELECT ONLY ONE

Games and activities

If meals were offered more weeks during the summer

If meals were offered more days during the week

Daily schedule (number of hours)

Walkable distance from home

Free transportation

Affordable program cost

Staff supervision

If child could bring meals and/or snacks home

Meals for parents/caregivers

Having friends of children going to the program

Being able to take the meals home or to another place away from the site

Shelter from heat and rain

Safe location

Other (PLEASE SPECIFY):

I am not interested in sending children in my household to a summer program that offers free meals to children ages 18 and younger

SECTION D. STAYING INFORMED ABOUT SUMMER MEALS PROGRAMS

D1. In the future, when is the best time to send you information about summer programs that offer free meals to children ages 18 and younger?

January February March April

May June July Other (please specify MONTH): ______________

D2. In the future, what would be the best way to provide you with information about summer programs that offer free meals to children ages 18 and younger?

SELECT UP TO THREE

Flyer or poster at child’s school

Flyer or poster at local government or public assistance office

Flyer or poster at local food bank

Flyer or poster at church or other community group

Television or radio

Poster or billboard on a bus stop/bus/train

Toll-free hotline

Internet or social media

Mail

Email or text message

U.S. Department of Agriculture, Food and Nutrition Service (FNS) Site Finder

Other (please specify):

D3. If available, would you send this child to the program at <SITE NAME> next summer?

Yes  GO TO SECTION E

No

Don’t know/Not sure

D4. Which of the following are reasons this child may not go to the program at <SITE NAME> next summer?

SELECT ONE OR MORE

Childcare is not provided

Child's friends will not go

Child not interested

Child will go to another program

Child will stay somewhere else during the day/for the summer

Activities do not appeal to the child

Cost too much

Is not easy to get to

Location unsafe

Can’t take the meals home or to another place away from the site

No shelter from heat and rain

No transportation

Doesn’t provide the meals/snacks we want

Meals are not of high quality

Doesn’t offer education or sports and recreational activities

Inadequate supervision

Doesn’t have a good reputation

Other (please specify):

SECTION E. FOOD SITUATION IN YOUR HOUSEHOLD

The next 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.

E1. In the last 30 days…

We had enough of the kinds of food we wanted to eat  GO TO SECTION F

We had enough food but not always the kinds of food we wanted to eat

We sometimes did not have enough food to eat

We often did not have enough food to eat

E2. In the last 30 days, we worried whether our food would run out before we got money to buy more.

Often true

Sometimes true

Never true

Don’t know

E3. In the last 30 days, the food that we bought just didn’t last, and we didn’t have money to get more.

Often true

Sometimes true

Never true

Don’t know

E4. In the last 30 days, we couldn’t afford to eat balanced meals.

Often true

Sometimes true

Never true

Don’t know

E5. 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?

Yes

No  GO TO QUESTION E7

Don’t know  GO TO QUESTION E7

E6. In the last 30 days, on how many days did this happen?

|___|___| days

E7. In the last 30 days, did you (the parent or caregiver) ever eat less than you felt you should because there wasn’t enough money for food?

Yes

No

Don’t know

E8. 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

E9. In the last 30 days, did you lose weight because there wasn’t enough money for food?

Yes

No

Don’t know

E10. 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?

Yes

No  GO TO QUESTION E12

Don’t know  GO TO QUESTION E12

E11. In the last 30 days, on how many days did this happen?

|___|___| days

The next questions are about the food situation of your children. For each statement or question, please select one response that best describes your children’s food situation.

E12. In the last 30 days we relied on only a few kinds of low-cost food to feed the child(ren) because we were running out of food.

Often true

Sometimes true

Never true

Don’t know

E13. In the last 30 days we couldn’t feed the child(ren) a balanced meal because we couldn’t afford it.

Often true

Sometimes true

Never true

Don’t know

E14. In the last 30 days my child(ren) were not eating enough because we could not afford enough food.

Often true

Sometimes true

Never true

Don’t know

E15. In the last 30 days did you ever cut the size of any of your child(ren)’s meals because there wasn’t enough money for food?

Yes

No

Don’t know

E16. In the last 30 days did your child(ren) ever skip meals because there wasn’t enough money for food?

Yes

No  GO TO QUESTION E18

Don’t know GO TO QUESTION E18

E17. In the last 30 days, on how many days did this happen?

|___|___| days

E18. In the last 30 days was your child(ren) ever hungry but you just couldn’t afford more food?

Yes

No

Don’t know

E19. In the last 30 days did your child(ren) ever not eat for a whole day because there wasn’t enough money to buy food?

Yes

No

Don’t know

SECTION F. ABOUT YOU AND YOUR HOUSEHOLD

F1. How old are you?

18-29 years old

30-39 years old

40-49 years old

50-59 years old

60 or older

F2. Are you male or female?

Male

Female

F3. What language do you usually speak at home?

English

Spanish

Other (please specify):

F4. What is the highest level of school you have completed?

No schooling completed

Less than grade 12

12th grade

GED or alternative credential

Some college credit but no degree

Associate degree (for example: AA, AS)

Bachelor's degree (for example: BA, BS)

Master's degree (for example: MA, MS, MEng, MED, MSW, MBA)

Professional degree beyond bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)

Doctorate degree (for example: PhD, EdD)

F5. Last month, were you …?

With a job or business but not at work

Not working at a job or business

Working at a job or business

Looking for work

F6. Including yourself, how many adults ages 19 and older are now living in this household?

|___|___| Number of people in the household

F7. In the past 12 months, did anyone in your household:

SELECT ONE OR MORE

Go to a Head Start program?

Go to a daycare program or childcare center that provides meals and snacks at no cost?

Get free or reduced price lunch at school?

Get free or reduced price breakfast at school?

Get snacks at before or after school programs?

Get food from a food pantry, food bank, or soup kitchen?

F8. In the past 12 months, did anyone in your household receive:

SELECT ONE OR MORE

Financial assistance to pay rent or housing costs

Assistance from (STATE NAME FOR LIHEAP) to pay electric or gas utility bills

Help with paying medical expenses through (STATE NAME FOR MEDICAID)

Assistance from (STATE NAME FOR TANF)

Benefits from (STATE NAME FOR SNAP)

Benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

F9. FOR SITES IN SEBTC STATES ONLY + USE STATE TERMINOLOGY FOR SEBTC, IF KNOWN: Do you have a summer electronic benefits transfer (EBT) card to use specifically to purchase food for your child/children during the summer months? This is usually called Summer EBT or Summer Electronic Benefits Transfer for Children (SEBTC).

Yes

No

Don’t know

F10. Please indicate whether you or anyone in your household received income in the last 12 months from any of the following:

SELECT ONE OR MORE

Wages, salary, commissions, bonuses, or tips

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

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

F11. Which category best describes your total household income last year, before taxes or other deductions?

SELECT ONLY ONE

Under $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to 49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 or more

F12. 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

F13. We have the following address on file, is this still correct?

NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

Yes. We will send $10 to the name and address above.

No. Please let us know where to send $10 for this survey.

NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

F14. Would you be available for a follow-up telephone interview in the next month or so? The interview will take about an hour and you will receive $20 as a thank you.

No

Yes. Please let us know your contact information.

HOME NUMBER:

CELL PHONE NUMBER:

EMAIL ADDRESS:

F15. Because phone numbers and email addresses change over time, please tell us the name and contact information of two people who will know how to find you.

Contact Person # 1:

Phone Number for Contact Person # 1:

Contact Person # 2:

Phone Number for Contact Person # 2:

CAREGIVERS PLEASE HAVE YOUR CHILD/TEEN COMPLETE

THE REST OF THIS SURVEY. THEIR ANSWERS WILL HELP MAKE THE PROGRAM BETTER

If only one child in your household attended or attends the program at <SITE NAME> then have this child complete the remainder of the summer meals survey. 

• If this child is 12 years of age of younger, please help them complete the red pages.

• If this child is between 13 and 18 years of age, have them complete the blue pages.

 If more than one child in your household attended or attends the program at <SITE NAME>, then have the child who had the most recent birthday complete the remainder of the summer meals survey.

• If this child is 12 years of age of younger, please help them complete the red pages.

• If this child is between 13 and 18 years of age, have them complete the blue pages.

If your child or teen did not attend or will not attend the summer meal program at <SITE NAME> this summer:

• If you have a child 12 years of age or younger, THANK YOU FOR COMPLETING THIS SUMMER MEALS STUDY SURVEY.

• If you have a child between 13 and 18 years or age, have them complete the blue pages.