FoodAPS Field Test - Respondents

Attachment M. Memory Jogger

(To be used by respondents participating by the telephone)

NATIONAL FOOD STUDY PILOT

MEMORY JOGGER FOR PERSONS PARTICIPATING BY PHONE

Foods and Drinks Purchased or Free

Use this form to write down foods and drinks that you don’t have a receipt for.

Food Event #:

Name of PERSON who completed this form
DAY food/drink obtained	Mon Tue Wed Thu Fri Sat Sun
Name of PLACE where food was obtained
Address of PLACE where food was obtained
Name of PERSON who got the food
Enter total paid including tax and tip	$
Write each food and drink you got on a separate line. Please be as specific as possible with the description and size or amount.
Description of food or drink	Size or amount (ounces, grams, large, etc.)	How many?	Total amount paid after coupons, discounts, or savings