Respondents Individuals/Households - Elderly 60+

OMB Control Number: 0584-xxxx

Expiration Date: xx/xx/xxxx

Attachment D.5 Interview Screening Form

SNAP Senior Access Evaluation

Interview Information Sheet

Thank you for participating in this interview! To help us learn more about you for our research, please fill out the following information. Only the study team will see this information and the form will be kept private, except as otherwise required by law.

Zip code: _______________________

Age: 60- 64 Veteran: Yes

65 – 69 No

70 - 74

75- 79

80 +

Gender: Male I think of myself as: Lesbian or gay

Female Straight, not gay

Transgender Bisexual

Write-in: ______________ Something else

Prefer not to Answer Don’t know

Prefer not to Answer

Ethnicity: Hispanic or Latino

Not Hispanic or Latino

Race (please check all that apply): American Indian or Alaska Native

Asian

Black or African-American

Native Hawaiian or Other Pacific

Islander

White or Caucasian

Prefer not to Answer

Highest education level: 8^th grade or under

Some high school

High school diploma or GED

Associate’s Degree

Bachelor’s degree or equivalent

Some graduate school

Graduate Degree

Use of the internet (check all that apply): On my home computer

On my cell phone

At the library or other community site

On a friend or relative’s computer

Rarely or Never

Other (specify):

Disability*:

Yes, I have a disability

No, I don’t now have a disability

Prefer not to answer

*You are considered to have a disability if you have physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history of such an impairment or medical condition.

Household** Monthly Income: Less than $1,000

$1,001 – 1,500

$1501 – 1,999

$2,000 - 2,999

$3,000 or more

Number of people in the Household**: ____________

**Household is people who live together, buy food as a group, and prepare meals as a group.

Public reporting burden for this collection of information is estimated to average 6 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.