Appendix B5a. Household Survey (English)

APPENDIX B5a. (INSTRUMENT E1). HOUSEHOLD SURVEY

OMB Number 0584-0530

Expiration Date: 05/31/2025

Fourth Access, Participation, Eligibility and Certification Study Series (APEC IV)

ABOUT THE HOUSEHOLD SURVEY

For APEC IV, the household survey will be conducted via telephone or secure video call using Zoom for Government platform. During the household survey the respondent is asked questions about their income, and is eligible for an additional incentive for displaying at least one form of income documentation, where applicable. The respondent will have the option to complete the survey by phone during the outreach call and transition to Zoom to show income documentation or provide it by text or email. If they set an appointment to conduct the survey at a later point they will be able to: 1) complete the entire survey via zoom video call, 2) transition to video only for income section, or 3) conduct the survey by phone using the Zoom call in number and provide income documentation by text or email. We will provide the respondent with instructions on how to use Zoom on a computer, tablet, or phone.

When appropriate, we will request the respondent show the interviewer the income documentation during the secure video call. Showing documentation during the video conference call is the quickest and preferred way to verify their income documentation. If the respondent is unable or unwilling to show the documentation by video, we will ask if they can submit the income documentation via secure email or secure text message. The email will be received and verified by the home office field room. If they are unable and unwilling to show or provide documentation, they will not receive the additional incentive.

E1. HOUSEHOLD SURVEY

NOTES TO FNS REVIEWERS

Purpose:

The following notes to reviewers help to explain the overall flow of the household survey, including how certain sections and/or questions will be repeated where applicable. The notes are organized into overall comments followed by section or question specific notes. Reviewers are encouraged to print these pages and have them to the side while reviewing each section of the household survey.

____________________________________________________________________________________

General Notes:

1. The household survey will be a computer assisted telephone interview (CATI). The data collector will follow a programmed survey and enter responses directly into the CATI system.

2. This document only includes the survey questions and does not include any introductory/recruitment/consent scripts that are used prior to data collection.

3. For each question, the “Don’t Know”, “Not Applicable”, and “Refused” response options are often not listed on the hardcopy version of the survey. Once the survey is finalized, CATI program automatically provides these response options for each question.

4. The CATI program includes a feature for the data collector to add a comment to each question using a comment code.

5. Any text that should be read to the respondent by the data collector is presented as sentences in mixed case text. This includes questions, certain responses, transitions, introductions and optional probes or clarifications.

6. Text in ALL CAPS (often instructions or notes to the data collector and/or programmer) are not read aloud to the respondent.

7. For some questions, context specific text will be embedded in the question automatically. This includes information that is computer derived, calculated, or drawn from pre-loaded data about that household. Differential text choices are presented in (parentheses) while names or other specific variables from preloaded data are in [in a bracket] text.

8. Any words that should be emphasized to the respondent by the data collector are underlined.

9. In front of many questions is an indication of who is asked the question. This will help orient the reader to follow the various paths during the questionnaire.

10. At times boxes are used for instructions and directions. The wording in these boxes has been simplified to increase comprehension for the reader. When programmed for CAPI these instructions will become considerable more complicated.

11. The questions in Section D are revised for the purpose of the substudy on “Online vs Paper Application”.

Section H:

12. For each section, the data collector will specify if documentation was available.

13. The same question pathway will be triggered for each adult with a reported income source other than paid work. Follow-up questions are triggered if any of the following income sources are received by the household member, as reported in Section G.

• Unemployment compensation;

• worker’s compensation benefits;

• strike benefits;

• social security or railroad retirement income;

• public or private pensions, annuities, or survivor’s benefits;

• military cash benefits;

• veteran’s benefits;

• government disability benefits from supplemental security income (SSI);

• private disability benefits;

• alimony payments;

• child support payments;

• income from interest and dividends;

• rental income;

• profit or loss from nonfarm business, partnership, or professional practice;

• profit or loss from a farm;

• financial aid to college students;

• regular payments or withdrawals from large awards or settlements;

• regular contributions from persons outside the household;

• other income, such as net royalties, trusts, prize winnings, or bonuses;

• receipt of general assistance;

• non-military housing subsidy;

• black lung benefits; and/or

• other kinds of public benefits.

14 These follow up questions will be asked of the respondent for each additional source of income:

a. What amount was received in the payment during the [application month]?

b. How often was the reported payment made?

c. Was a supporting document about the source of income available to review? And if yes, data collector records the type of document provided.

15 If available on the documentation, the data collector will record the start and end date for the income period, and the year-to-date amount.

Section K:

16. Section K now includes additional language for respondents who opt to send their documentation via secure email or text, rather than display on screen during video call.

17. Section K now includes questions to recruit respondents from select SFAs to participation in the In-Person Household Survey subsidy.

STUDY ID NUMBER: | | | | | | | | |

DATE: | | | / | | | / | 2 | 0 | 2 | |

MONTH DAY YEAR

INTERVIEWER ID NUMBER: | | | | | |

INTRODUCTION AND OBTAINING INFORMED CONSENT

INTRO1. TIME INTERVIEW BEGAN: | | |:| | |

HOUR MINUTE

AM 1

PM 2

PROGRAMMER NOTE 01: AUTOMATICALLY RECORD DATE AND TIME INTERVIEW BEGAN.

INTRO2. INTERVIEW MODE:

[Zoom, with video] 1

[Zoom, without video] 2

OTHER, SPECIFY 96

________________________________________________

INTRO3. INDICATE THE PARENT/GUARDIAN RESPONDENT

[identified parent/guardian] 1

[second identified parent/guardian 2

ANOTHER PERSON, SPECIFY 96

PROGRAMMER NOTE 01a: LIST ALL PARENTS IN STUDY RECORDS

INTRO4. CODE IF OBVIOUS, OR ASK: Does [TARGET STUDENT NAME] live with you?

YES 1

NO 2 (Go to Script 4)

INTRO TO CONSENT: ASK RESPONDENT TO REFER TO THE CONSENT FORM SENT VIA EMAIL OR MAIL

Thank you for agreeing to be part of the National School Meal Study (NSMS). This interview takes about 45 minutes to complete. You will receive up to $60.00 for completing the survey and having income documents available as our thank you. Participation in this study is voluntary and will not affect any benefits you or your child may receive now or in the future. All information is kept private and will never be used in any way that could identify you or your child.

Please review the document that describes this study and what you are being asked to do. ASK RESPONDENT TO REFER TO THE CONSENT FORM. Let me know if you have any questions.

REFER TO PRIVACY SECTION OF CONSENT FORM: This section describes the steps the study takes to protect your privacy. Among those steps is the agreement I signed to keep your information private.

WHEN PARENT/GUARDIAN IS FINISHED, ASK: Do you have any questions? TAKE TIME TO ANSWER ALL QUESTIONS APPROPRIATELY.

Now, I would like get your verbal consent to indicate you agree to complete the interview.

INTERVIEWER: READ THE CONSENT FORM TO RESPONDENT IF REQUESTED OR IT APPEARS THERE IS READING DIFFICULTY.

CONTINUE 1

INTRO5. DID PARENT/GUARDIAN GIVE VERBAL CONSENT?

YES 1(GO TO INTRO6)

NO 2 (GO TO SCRIPT 2)

PROGRAMMER: DISPLAY THE CASE ID NUMBER

INTRO6. We previously [emailed/mailed] you a copy of the consent form for your own records. Now, unless you have any questions, we can get started.

CONTINUE 1

INTRO7. We would like to record your questions and answers for training and data quality. I’d like to continue now unless you have questions.

CONTINUE 1

DID NOT ALLOW RECORDING 7 (GO TO INTRO9)

INTRO8. Today is [insert date]. The recorder is running, is it okay if I continue?

CONTINUE 1 (GO TO SECTION A)

DID NOT ALLOW RECORDING 7 (GO TOINTRO9)

INTRO9. That’s fine. The interview will not be recorded.

CONTINUE 1 (GO TO SECTION A)

INTRO10. INTERVIEWER: USE STUDY PROCEDURES TO DOCUMENT WHY CONSENT WAS NOT OBTAINED OR WHY INTERVIEW WAS NOT CONTINUED.

NOT A GOOD TIME, SCHEDULE REVISIT (CLOSE SCRIPT # 1)

REFUSED OR NOT INTERESTED (CLOSE SCRIPT # 2)

NOT SURE ABOUT DOING OR HAS QUESTIONS (CLOSE SCRIPT # 2)

IDENTIFIED PARENT/GUARDIAN NOT AVAILABLE (CLOSE SCRIPT # 3)

IDENTIFIED PARENT/GUARDIAN IS NOT CORRECT (CLOSE SCRIPT # 4)

NO LONGER HAS CUSTODY OF FOSTER CHILD (CLOSE SCRIPT # 4)

TARGET STUDENT RESIDES IN GROUP HOME (CLOSE SCRIPT # 4)

TARGET STUDENT DECEASED (CLOSE SCRIPT # 5)

CLOSE SCRIPTS:

SCRIPT 1: SCHEDULE NEW APPOINTMENT: Let’s try to find a time that works better for you. What date and time would work for you? INTERVIEWER: CHECK YOUR AVAILABILITY FOR THAT TIME AND DATE, IF AVAILABLE CONFIRM DATE AND TIME AND ADD TO YOUR CALENDAR. IF NOT AVAILABLE, I’m sorry I’m not available at that time but I am available INSERT DATE AND TIME, does that work for you? Thank you for your time today.

SCRIPT 2: ADDRESS RESPONDENT CONCERNS: APPLY REFUSAL CONVERSION TECHNIQUES AND FAQS TO ANSWER QUESTIONS OR ADDRESS CONCERNS.

AGREED TO PARTICIPATE (GO BACK TO 03)

REFUSAL (GO TO SCRIPT #5)

SCRIPT 3: COLLECT GOOD TIME TO REACH IDENTIFIED PARENT/GUARDIAN: I am sorry that I missed [parent/guardian] today. When would be a good time to contact them by phone to set a new appointment? RECORD THE CALL BACK INFORMATION. Thank you for your time today.

SCRIPT 4: CONTACT INFORMATION FOR BEST ADULT TO ANSWER QUESTIONS: I’m sorry but I must speak with a parent or guardian who lives with [TARGET STUDENT NAME]. IF NEEDED: When would be a good time to contact ( them) by phone to set a new appointment? RECORD THE CONTACT INFORMATION. Thank you for your time today.

SCRIPT 5: REFUSAL: We accept your decision not to participate. Thank you for your time today. (GO TO INTRO10)

SECTION A: ENROLLMENT STATUS

Section A determines whether the student attended the [Target School]. The interview will not be conducted if the student never attended the school during the school year. In addition, if the student has not and will not apply for meal benefits for SY 2023-2024, the interview will not be conducted.

A1_INTRO These next questions ask about [Target Student Name] and [Target Student Name’s usual weekly attendance at [Target School].

CONTINUE……………………………………….1

A2. Does [Target Student Name] currently attend [Target School]?

YES 1 (GO TO A5)

NO 2

A3. Does [Target Student Name] attend another school?

IF YES, ASK A3a.

A3a. What school does [Target Student Name] attend now?

SCHOOL NAME:

CITY, STATE:

A4. When did [Target Student Name] stop attending [Target School]?

PROBE: Was that in the beginning, middle, or the end of the month? IF BEGINNING ENTER 5, IF MIDDLE ENTER 15, IF END ENTER 25.

|___|___| / |___|___| / |___|___| (GO TO A7)

MONTH DAY YEAR

A5. Has [Target Student Name] attended [Target School] from the beginning of the school year?

PROBE: By “the school year” I mean the current school year 2023-2024.

YES……………….(GO TO SECTION B if sampled from SY 2023/2024 roster.

GO TO A8 if sampled from SY 2022/2023 roster.)

NO………………. (ASK A5a)

A5a. When did [Target Student Name] begin attending [Target School] this school year?

PROBE: Was that in the beginning, middle, or the end of the month? IF BEGINNING ENTER DAY AS 5, IF MIDDLE ENTER DAY AS 15, IF END ENTER DAY AS 25.

|___|___| / |___|___| / |___|___| (GO TO SECTION B)

MONTH DAY YEAR

A7. Thank you for your time. This interview is specifically for students who attend [Target School] this school year 2023-24. We will not be able to conduct an interview with you. (END SURVEY)

A8. Did or will your household submit an application for free or reduced-priced meals for [Target Student Name] for school year 2023-24?

YES, an application was submitted 1

YES, an application will be submitted 2

NO, an application has not and will not be submitted 3 (GO TO A10)

A9. When did/will you submit the application for free or reduced-priced meals for [Target Student Name] for school year 2023-24?

|___|___| / |___|___|___|___| (GO TO SECTION B)

MONTH / YEAR

NOTE TO PROGRAMMERS: USE THIS MONTH AND YEAR AS THE “APPLICATION MONTH” FOR STUDENTS SAMPLED FROM THE 2022-2023 ROSTER.

A10. Was [Target Student Name] directly certified for free meals for school year 2023-24? That is, did the school determine that [Target Student Name] is eligible for free or reduced-price meals?

YES 1 (GO TO SECTION B)

NO 2 (GO TO A11)

DON”T KNOW 3 (GO TO SECTION B)

A11. Thank you for your time. This interview is specifically for students who applied for or were directly certified for free or reduced-priced meals for school year 2023-2024. We will not be able to conduct an interview with you. (END SURVEY)

SECTION B: PARTICIPATION IN SCHOOL BREAKFAST AND LUNCH PROGRAMS

Section B asks about the student’s participation in the school breakfast and/or lunch program during the most recent 5-day school week. This section also asks for those students who did not eat the school breakfast or lunch on any day that they attended school, why that is the case.

B1. 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 each day during the last full week of school. I am referring to the meals provided under the School Breakfast and School Lunch Programs. They are the meals that are on the menu for free or a single price, as opposed to individual foods that are priced and bought separately.

CONTINUE………………………..1

B2START. When was the last full week of school?

INTERVIEWER: USE CALENDAR TO ASSIST.

ENTER A VALID DATE WITH THE WEEK STARTING ON MONDAY.

B2END AUTOCODE B2END WITH THE FRIDAY OF THE WEEK STARTING ON MONDAY IN B2START

B3. Now please think about the last full week of school—that would be (Monday through Friday last week/from Monday—DATE to Friday—DATE).

Which days that week did [Target Student Name] attend school either all day or part of the day?

NOTE TO INTERVIEWER: IF RESPONDENT MAKES A STATEMENT ABOUT THE ENTIRE WEEK, ENTER DATA FOR EACH DATE.

ATTENDED DID NOT ATTEND

a. MONDAY, DATE 1 2

b. TUESDAY, DATE 1 2

c. WEDNESDAY, DATE 1 2

d. THURSDAY, DATE 1 2

e. FRIDAY, DATE 1 2

BOX 1

REPEAT B4A-B5 FOR EACH DAY TARGET STUDENT ATTENDED SCHOOL (B3a-e=1). WHEN ALL DAYS ARE ASKED, CONTINUE TO BOX 2.

B4a. Did [Target Student Name] eat breakfast at school (on DAY, DATE)?

YES 1

NO 2 (GO TO BOX 1)

B5. Was that breakfast through the National School Breakfast program?

PROBE: The National School Breakfast Program consists of a set of food items from the menu that were either free or, if paid for, were purchased for a single price, as opposed to individual foods that are priced and bought separately.

YES 1

NO 2

BOX 2

ASK B6 ABOUT [TARGET STUDENT NAME] WHO ATTENDED SCHOOL AT LEAST ONE DAY FOR THE WEEK (B3a-e = 1) AND DID NOT PARTICIPATE IN THE SCHOOL BREAKFAST PROGRAM ON ANY DAY THEY ATTENDED SCHOOL. (B4a = 2 or B5 = 2) OTHERWISE GO TO B8a.

B6. You just mentioned that [Target Student Name] did not eat breakfast provided by the School Breakfast Program on any day (she/he/they) attended school during the last week [Target Student Name] went to school. Why didn’t [Target Student Name] eat the school breakfast during that week?

AFTER RESPONSE, SAY: Were there other reasons? (MARK ALL THAT APPLY)

EATS BREAKFAST AT HOME 1

BRINGS BREAKFAST FROM HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT BREAKFAST 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY CHILDREN EAT
SCHOOL BREAKFASTS 8

STUDENT DOES NOT EAT SCHOOL BREAKFAST
BECAUSE FRIENDS DO NOT EAT IT 9

CODE IF PREVIOUSLY MENTIONED: NOT IN SCHOOL

THAT WEEK/OUT SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD EARLY MORNING CLASSES THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR BREAKFAST………………………….. 14

PREFERS TO BUY SELECT ITEMS A LA CARTE 15

IT IS NOT CONVENIENT…………………………………………….. 16

OTHER (SPECIFY) 96

BOX 3

REPEAT B8a THROUGH B9 FOR ALL DAYS [TARGET STUDENT NAME] ATTENDED SCHOOL FOR THE WEEK. (B3a-e=1)

B8a. Did [Target Student Name] eat lunch at school (on DAY, DATE)?

YES 1

NO 2 (GO TO BOX 3)

B9. Was that lunch provided through the National School Lunch Program?

PROBE: The National School Lunch Program consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.

YES 1

NO 2

BOX 4

ASK B10 ABOUT [TARGET STUDENT NAME] WHO ATTENDED SCHOOL AT LEAST ONE DAY FOR THE WEEK (B3a-e = 1) AND DID NOT PARTICIPATE IN THE SCHOOL LUNCH PROGRAM ON ANY DAY THEY ATTENDED SCHOOL. (B8a = 2 or B9 = 2) OTHERWISE GO TO B12.

B10. You mentioned that [Target Student Name] did not eat the school lunch on any day [Target Student Name] attended school. Why didn’t [Target Student Name] get the school lunch during that week?

AFTER RESPONSE, SAY: Were there any other reasons? (MARK ALL THAT APPLY).

PREFERS TO BRING LUNCH FROM HOME 1

EATS LUNCH AT HOME 2

DOES NOT LIKE THE FOOD AT SCHOOL 3

NOT ENOUGH TIME TO EAT AT SCHOOL 4

STUDENT DOES NOT EAT LUNCH 5

ON A DIET 6

DOES NOT LIKE WAITING IN LINE 7

STUDENT THINKS ONLY NEEDY CHILDREN EAT
SCHOOL LUNCHES 8

STUDENT DOES NOT EAT SCHOOL LUNCH
BECAUSE FRIENDS DO NOT EAT IT 9

CODE IF PREVIOUSLY MENTIONED: NOT IN SCHOOL

THAT WEEK/SICK ALL WEEK 10

LATE FOR SCHOOL EVERY DAY THAT WEEK 11

HAD CLASSES DURING LUNCH PERIOD THAT WEEK 12

STUDENT OR PARENT TOO EMBARRASSED TO
PARTICIPATE 13

GOES OFF CAMPUS FOR LUNCH …… 14

PREFERS TO BUY SELECT ITEMS A LA CARTE 15

NOT HUNGRY/DID NOT FEEL LIKE EATING……………………. ..16

OTHER (SPECIFY) 96

B12. INTERVIEWER: DID [TARGET STUDENT NAME] HELP THE RESPONDENT WITH THE QUESTIONS ON MEALS EATEN AT SCHOOL?

YES 1 (GO TO SECTION C)

NO 2 (GO TO SECTION C)

BOX 5

INTERVIEWER: ASK B13 AND B14 IF [TARGET STUDENT NAME] NO LONGER ATTENDS THE [TARGET SCHOOL] (A2=2)

B13. I am going to ask you how often [Target Student Name] usually had school breakfast or lunch each week when [Target Student Name] was going to [Target School]. By school breakfast or lunch, I mean the meals [Target Student Name]’s school provides to students under the National School Breakfast and School Lunch Programs. School meals are meals that include a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.

When [Target Student Name] was going to [Target School], how many days in an average week did [Target Student Name] eat a school breakfast?

|___|

NUMBER OF DAYS ATE SCHOOL BREAKFASTS

INTERVIEWER: IF NONE, DID NOT EAT SCHOOL BREAKFAST, ENTER 0

B14. When [Target Student Name] was going to [Target School], how many days in an average week did [Target Student Name] eat a school lunch?

|___|

NUMBER OF DAYS ATE SCHOOL LUNCHES

INTERVIEWER: IF NONE, DID NOT EAT SCHOOL BREAKFAST, ENTER 0

SECTION C: PERCEPTIONS OF SCHOOL MEALS

Section C asks the parent/guardian about what they see as the value of school meals as well as what they think the student values in school meals. As a reminder, ‘don’t know’, ‘refused’ and ‘add comment’ will be programed as a response option for all questions.

C­_INTRO1 The next questions ask for your own opinions of the school meals program, which includes both the breakfast program and the lunch program.

C1. As a parent or guardian, would you rate the overall school meals program at [Target Student Name] school as….

Excellent 1

Very good 2

Good 3

Fair, or 4

Poor 5

NO OPINION 6

C2. In what ways does the availability of school meals help you as a parent or guardian? (MARK ALL THAT APPLY).

SAVES ME MONEY ON MEALS 1

STUDENT GETS A HEALTHY MEAL 2

DON’T HAVE TO WORRY ABOUT THEIR LUNCH 3

DON’T HAVE TO WORRY ABOUT THEIR BREAKFAST 4

SAVES ME TIME 5

OTHER 6

IT DOES NOT HELP ME 7

OTHER (SPECIFY) 96

C3. What would make the school meals programs more helpful to you? (MARK ALL THAT APPLY).

IF I DIDN’T HAVE TO WORRY ABOUT FILLING OUT AN APPLICATION 1

IF I GOT MEALS FOR FREE 2

IF I GOT MEALS AT A LOWER CLOST 3

IF I DIDN’T HAVE TO THINK ABOUT HOW TO PAY

(E.G. PUTTING MONEY IN ACCOUNT, GIVING STUDENT MONEY) 4

IF I KNEW/TRUSTED THE MEALS WERE HEALTHY 5

IF MY STUDENT LIKED THE FOOD 6

IF MY STUDENT PICKED HEALTHY FOOD 7

IF THE MEALS MET MY STUDENTS DIETARY RESTRICTIONS

(E.G., ALLERGIES, RELIGIOUS RESTRICTIONS, VEGETARIAN) 8

NOTHING 9

OTHER (SPECIFY) 96

C­_INTRO2 The next questions are about what you think [Target Student Name]’s opinions are about the school meals.

C4. Overall, how do you think [Target Student Name] would rate the school meals they receive? Would you say they find school meals ….

Excellent 1

Very good 2

Good 3

Fair, or 4

Poor 5

SECTION D: PERCEPTIONS OF THE HOUSEHOLD APPLICATION

Section D asks several questions related to the perceived difficulty in completing the application for free or reduced-priced school meals.

AS A REMINDER, ‘DON’T KNOW’, REFUSED, AND ‘ADD COMMENT’ WILL BE PROGRAMMED AS A RESPONSE OPTION FOR ALL QUESTIONS.

Next, I would like to ask questions about the application your household filled out for the school meal programs for this school year.

ASK EVERYONE.

D0. Did your household complete an application for free or reduced-priced meals?

YES 1

NO 2 GO TO SECTION E

D1. How easy or difficult was it for your household to complete the application? Was it….

Very easy, 1

Somewhat easy, 2

Neither easy nor difficult, 3

Somewhat difficult, or 4

Very difficult to complete? 5

D2. Was your household able to fill out the application in the language of your choice?

YES 1

NO 2

THERE IS NO QUESTION D3.

D4. How did your household submit the application?

Hardcopy or paper 1 (GO TO D11a)

Via email 2 (GO TO D11a)

Online, but not email 3 (GO TO D11a)

Over the phone, or 4

Some other way (SPECIFY)…………………………96 (GO TO D11a)

D5. [IF ONLINE (D4 = 3)] Thinking about the format of the online application, did you enter all of the information on one screen, or did you navigate through a step-by-step process on several screens to enter your information?” (PROBE AS NEEDED)

INTERACTIVE (QXQ PROTOTYPE) 1

TRADITIONAL 2

[INTERVIEWER: ADD DETAILS IN COMMENTS TO CAPTURE RESEPONDENT’S DESCRIPTION].

[IF INTERACTIVE (D5 = 1)] For the purposes of this survey, we will be referring to the application you just described as the “interactive online application.”

D6. [IF INTERACTIVE (D5 = 1)] Have you ever submitted an application for school meals in a different format than the interactive application? For example, an online application that doesn’t have separate pages for each step, or a paper application.

YES 1

NO 2 (GO TO D9)

D7. [IF INTERACTIVE (D5=1) AND D6 = 1] Please think about the interactive online application compared to other school meal applications you have completed in the past. Would you say the interactive application was...

Much easier to complete than other school meal applications you have completed, 1

Somewhat easier, 2

Neither easier nor more difficult, 3

Somewhat more difficult, or 4

Much more difficult to complete? 5

[IF INTERACTIVE (D5=1) AND D6 = 1] Now let’s think about specific aspects of the interactive online application.

	Was the interactive online application easier or more difficult than other types of school meal applications you’ve submitted in the past with regard to…	RESPONSE
D8a.	…Understanding how to enter the information the interactive form is asking for...? Was it…	Much easier, 1 Somewhat easier, 2 Neither easier nor more difficult, 3 Somewhat more difficult, or 4 Much more difficult than other school meal applications? 5
D8b.	…Listing all of the students in your household on the interactive application? Was it…	Much easier, 1 Somewhat easier, 2 Neither easier nor more difficult, 3 Somewhat more difficult, or 4 Much more difficult than other school meal applications? 5
D8c.	…How to report whether you receive SNAP, TANF, or Medicaid? (IF NEEDED: Was it …)	Much easier, 1 Somewhat easier, 2 Neither easier nor more difficult, 3 Somewhat more difficult, or 4 Much more difficult than other school meal applications? 5
D8d.	…Reporting your child’s income (if any)? (IF NEEDED: Was it…)	Much easier, 1 Somewhat easier, 2 Neither easier nor more difficult, 3 Somewhat more difficult, or 4 Much more difficult than other school meal applications? 5 NOT APPLICABLE……………….7
D8e.	…Listing all of the adults in your household? (IF NEEDED: Was it…)	Much easier 1 Somewhat easier 2 Neither easier nor more difficult 3 Somewhat more difficult 4 Much more difficult than other school meal applications 5
D8f.	…Understanding how to report different types of income for each adult in your household? (IF NEEDED: Was it…)	Much easier 1 Somewhat easier 2 Neither easier nor more difficult 3 Somewhat more difficult 4 Much more difficult than other school meal applications 5
D8g.	…Understanding how to report how often you receive your income, for example, monthly, twice monthly, weekly? (IF NEEDED: Was it…)	Much easier 1 Somewhat easier 2 Neither easier nor more difficult 3 Somewhat more difficult 4 Much more difficult than other school meal applications 5

D9. [IF INTERACTIVE (D5 = 1)] Was there anything confusing or unclear about the interactive online application?

YES 1

NO 2 (GO TO D11a)

DON’T REMEMBER 3 (GO TO D11a)

D10. [IF D9=1] What was confusing or unclear about the interactive online application? (CODE ALL THAT APPLY.)

INSTRUCTIONS AT THE BEGINNING OF THE APPLICATION….1

HOW TO ADD STUDENTS 2

HOW TO REMOVE STUDENTS 4

HOW TO PROVIDE SNAP, TANF, AND/OR FDPIR

CASE NUMBERS 5

HOW TO ADD ADULTS IN THE HOUSEHOLD 6

HOW TO REMOVE ADULTS IN THE HOUSEHOLD 7

HOW TO REPORT INCOME FROM WORK 8

HOW TO REPORT INCOME FROM PUBLIC ASSISTANCE,

ALIMONY, OR CHILD SUPPORT 9

HOW TO REPORT INCOME FROM PENSIONS

OR RETIREMENT 10

HOW TO REPORT OTHER INCOME 11

OTHER 96

	The next set of questions asks whether you understood specific parts of the application.	RESPONSE
D11a.	Did you understand which adults and children to include in the application?	YES 1 NO 2
D11b.	Did you understand what types of income to include in the application?	YES 1 NO 2
D11c.	Did you understand which household members’ income to include on the application?	YES 1 NO 2
D11d.	Did you understand how to report each type of income on the application?	YES 1 NO 2
D11e.	Did you understand which benefits payments, like SNAP and TANF, to include on the application?	YES 1 NO 2

D12. How confident are you that your household completed the application correctly?

Very confident 1

Somewhat confident 2

Not confident 3

SECTION E: CATEGORICAL ELIGIBILITY

NOTE TO REVIEWER: Section E asks a series of questions to determine if the target student was categorically eligible for free meals. Households that are categorically eligible will skip out of the questions on household size and income (Sections F, G, H, and I).

E_INTRO1: Next, I would like to ask questions about [Target Student Name], and benefits your household may receive.

CONTINUE………………………..1

E1. What is [Target Student Name]’s relationship to you? Is [Target Student Name] your biological child, stepchild or adopted child, a foster child or something else? (IF SOMETHING ELSE:) What is that relationship.

BIOLOGICAL CHILD 1

STEPCHILD OR ADOPTED CHILD 2

FOSTER CHILD 3

SIBLING (BROTHER OR SISTER) 4

NEPHEW OR NIECE 5

COUSIN 6

GRANDCHILD 7

OTHER RELATIVE 8

NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 9

OTHER (SPECIFY) 96

THERE IS NO QUESTION E2.

E3. CONFIRM IF DATE IS PRE-FILLED

IF NOT PRE-FILLED ASK: What is [Target Student Name]’s date of birth?

|___|___|/|___|___|/|___|___|

MONTH DAY YEAR

E4. Did [Target Student Name] live with you in [Application Month, Year]?

YES 1

NO 2

E4a. How many other children, in addition to [Target Student Name] lived with you in [application month and year]?

|__|__|

ENTER NUMBER (enter 0, if no other children):

INTERVIEWER: MAKE SURE THIS NUMBER DOES NOT INCLUDE THE TARGET STUDENT IT SHOULD ONLY INCLUDE THE NUMBER OF ADDITIONAL CHILDREN.

E4b. Are you currently married?

YES 1

NO 2

PROGRAMMER NOTE: INSTRUCTIONS FOR DIFFERENTIAL TEXT IN THIS SECTION: “you, your spouse, and/or child/children”:

• IF THERE IS MORE THAN ONE CHILD (E4a ≠ 0), THEN TEXT SHOULD READ “CHILDREN”. IF ONLY ONE CHILD, THEN TEXT SHOULD READ “CHILD”

• IF RESPONDENT IS MARRIED (E4b = 1), THEN TEXT SHOULD INCLUDE “YOUR SPOUSE”. OTHERWISE IT SHOULD READ “YOU”.

BOX 6

IF [TARGET STUDENT NAME] IS A FOSTER CHILD (E1 = 3) GO TO SECTION J. [TARGET STUDENT NAME] IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

HOUSEHOLD BENEFITS

E_INTRO2: The next questions are about benefits received through government programs by anyone in your household. Your household includes people that you usually live with and share income and expenses with. This can include relatives and non-relatives as well as people who are temporarily away, for example, at school or college, in a hospital, deployed, or who live away from home for their work.

It will be helpful to review any documentation you have about your household’s participation in benefits programs so that we can work together to answer the questions.

INTERVIEWER: GIVE TIME FOR RESPONDENT TO COLLECT DOCUMENTATION. WHENEVER POSSIBLE, USE AVAILABLE DOCUMENTS TO VERIFY OR CLARIFY RESPONDENT’S RESPONSES.

INTERVIEWER: IF RESPONDENT IS USING BENEFITS DOCUMENTATION, INSTRUCT RESPONDENT TO TURN THE VIDEO CAMERA ON SO YOU CAN VERIFY THE INFORMATION THROUGHOUT THIS SECTION. YOU MAY NEED THEM TO HOLD THE DOCUMENT CLOSE TO THE SCREEN FOR YOUR REVIEW.

TANF BENEFITS

E_INTRO 3: Let’s discuss TANF benefits also known as Temporary Assistance for Needy Families or [State Name for TANF].

E5 During [application month and year], did you, (your spouse), or (child/children) receive Temporary Assistance for Needy Families, or [State Name for TANF]?

YES 1

NO 2 (GO TO E9)

E6. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 96

E7. Do you have the TANF EBT card, also known as [State Name for TANF] card, that you can show me?

YES 1

NO 2 (GO TO E9)

E8. INTERVIEWER: DID THE RESPONDENT SHOW A VALID TANF CARD?

YES 1

NO 2

E9. Does anyone else in your household receive TANF?

YES……………………………………….. 1

NO …… 2 (GO TO E11)

E10. Do you share income or expenses with this person?

YES……………………………………….. 1 (GO TO E10a)

NO 2 (GO TO E11)

E10a. Do you have this persons TANF EBT card, also known as [State Name for TANF] card, that you can show me?

YES……………………………………….. 1 (GO TO E10b)

NO 2 (GO TO E11)

E10b. INTERVIEWER: DID THE RESPONDENT SHOW A VALID TANF CARD?

YES 1

NO 2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES TANF BENEFITS (E5 = 1) OR (E9=1 and E10 = 1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

SNAP BENEFITS

E_INTRO 4: Now let’s discuss any Supplemental Nutrition Assistance Program or SNAP benefits you, your spouse, and/or your child/children may receive.

E11. During [application month and year], did you, (your spouse), or (child/children) receive Supplemental Nutrition Assistance Program benefits (formerly known as Food Stamps), also known as [State Name for SNAP] ?

YES 1

NO 2 (GO TO E15)

E12. How often do you receive this payment?

WEEKLY 1

EVERY TWO WEEKS 2

TWICE MONTHLY 3

MONTHLY 4

OTHER (SPECIFY) 96

E13. Do you have the SNAP EBT card, also known as [State Name for SNAP] card, that you can show me?

YES 1

NO 2 (GO TO E15)

E14. INTERVIEWER: DID THE RESPONDENT SHOW A VALID SNAP CARD?

YES 1

NO 2

E15. Does anyone else in your household receive SNAP, also known as [State Name for SNAP]?

YES………………………………………..1

NO 2 (GO TO E17)

E16. Do you share income or expenses with this person?

YES………………………………………..1 (GO TO E16a)

NO ……2

E16a. Do you have this persons SNAP EBT card, also known as [State Name for SNAP] card, that you can show me?

YES 1 (GO TO E16b)

NO 2 (GO TO E17)

E16b. INTERVIEWER: DID THE RESPONDENT SHOW A VALID SNAP EBT CARD?

YES 1

NO 2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES SNAP BENEFITS (E11= 1) OR E15 = 1 and E16 = 1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

OTHER BENEFITS

E17. During [application month and year], did you, (your spouse), or (child/children) participate in the Food Distribution Program for Indian Reservations (FDPIR)?

YES 1

NO 2 (GO TO E20)

E18. Do you have the FDPIR verification letter that you can show me?

YES 1

NO 2 (GO TO SECTION J)

E19. INTERVIEWER: DID THE RESPONDENT SHOW A FDPIR VERIFICATION LETTER?

YES 1

NO 2

E20. Does anyone else in your household receive FDPIR benefits?

YES………………………………………..1

NO 2 (GO TO E22)

E21. Do you share income or expenses with this person?

YES………………………………………..1

NO ……2

E21a. Do you have this persons FDPIR verification letter that you can show me?

YES 1 (GO TO E21b)

NO 2 (GO TO E22)

E21b. INTERVIEWER: DID THE RESPONDENT SHOW A FDPIR VERIFICATION LETTER??

YES 1

NO 2

PROGRAMMER NOTE: IF HOUSEHOLD RECEIVES FDPIR BENEFITS (E17 = 1) OR (E20 = 1 and E21 =1) GO TO SECTION J. THIS MEANS THE TARGET STUDENT IS CATEGORICALLY ELIGIBLE FOR FREE MEALS.

E22. During [application month and year], did any child in your household receive Medicaid benefits?

YES 1

NO . 2 (GO TO SECTION F)

E23. Do you have the Medicaid card or other documentation that shows a child in your household receives Medicaid benefits, that you can show me?

YES 1

NO 2 (GO TO SECTION F)

E24. INTERVIEWER: DID THE RESPONDENT SHOW A MEDICAID CARD?

MEDICAID CARD 1

OTHER DOCUMENTATION 2

NO . 3

SECTION F: HOUSEHOLD COMPOSITION

Section F 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, age, grade level for children and occupation for adults. In this section, we also ask if anyone else lived in the household during the application month.

HH­_ROSTER_FI Next, I would like to ask questions about the people who are part of your household.

ASK EVERYONE.

F1. I have your name recorded as [parent/guardian name]. Is this correct?

INTERVIEWER: SPELLING OF RECORDED NAME SHOULD BE CONFIRMED.

IF FIRST AND LAST NAME ARE NOT DISPLAYED, ANSWER NO AND COLLECT FULL NAME AT F2.

YES 1 (GO TO F3)

NO 2 (GO TO F2)

F2. May I please have the correct spelling of your full name?

FIRST NAME LAST NAME

F3. Not including yourself, how many people usually live with you? Please include babies, small children, and people who are not related to you, as well as people who are temporarily away, for example, at school or college, in a hospital, deployed, or who live away from home for their work. Do not include people are who are incarcerated or children who do not live with you.

|___|___|

PROGRAMMER: IF INTRO4 = 1 (LIVES WITH TARGET STUDENT) OR E4= 1 (LIVES WITH TARGET STUDENT) AND F3 = 0 DISPLAY THE FOLLOWING ERROR MESSAGE” SINCE [TARGET STUDENT NAME] LIVES/LIVED WITH YOU THE RESPONSE MUST BE 1 OR GREATER”

F5. Please tell me the first name of everyone who usually lives with you.

FILL IN NAME OF RESPONDENT IN POSITION #1

FILL IN NAME OF TARGET STUDENT IN POSITION#2.

PROBE: Who else lives with you?

________________________ RESPONDENT (NAME # 1)	________________________ NAME # 6	________________________ NAME # 11
________________________ TARGET STUDENT (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 7

PROGRAMMER NOTE: ALLOW AS MANY RECORDS AS NEEDED TO LIST ENTIRE HOUSEHOLD MEMBERSHIP. QUESTIONS F6-12 WILL BE ASKED OF EVERY MEMBER OF THE HOUSEHOLD, EXCEPT [TARGET STUDENT NAME] WHICH WAS ASKED IN SECTION E.

SKIP QUESTION F6 WHEN ASKING ABOUT THE RESPONDENT.

NOTE TO READER: FOR DEMONSTRATION PURPOSES QUESTIONS F6 THROUGH F12 ARE SHOWN FOR 3 HOUSEHOLD MEMBERS. WHEN PROGRAMMED, THESE QUESTIONS WILL LOOP TO BE ASKED OF ALL HOUSEHOLD MEMBERS.

RECORD RESPONDENT FIRST, TARGET STUDENT SECOND, THEN RECORD NAMES OF ALL OTHER HOUSEHOLD MEMBERS ACROSS THE GRID FIRST, THEN ASK F6 THROUGH F12 FOR EACH PERSON.

	____________________ RESPONDENT	____________________ TARGET STUDENT(NAME #2)	____________________ NAME #3
F6. What is NAME's relationship to you?		BIOLOGICAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 FOSTER CHILD 3 SPOUSE OR DOMESTIC PARTNER 4 BOYFRIEND, GIRLFRIEND, OR PARTNER 5 PARENT 6 STEPPARENT 7 GRANDPARENT OR GREAT-GRANDPARENT 8 AUNT, UNCLE, GREAT- AUNT, OR GREAT- UNCLE 9 SIBLING (BROTHER OR SISTER) 10 NEPHEW OR NIECE 11 COUSIN 12 GRANDCHILD 13 OTHER RELATIVE OR IN-LAW 14 NON-RELATIVE 15 OTHER (SPECIFY) 96	BIOLOGICAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 FOSTER CHILD 3 SPOUSE OR DOMESTIC PARTNER 4 BOYFRIEND, GIRLFRIEND, OR PARTNER 5 PARENT 6 STEPPARENT 7 GRANDPARENT OR GREAT-GRANDPARENT 8 AUNT, UNCLE, GREAT- AUNT, OR GREAT- UNCLE 9 SIBLING (BROTHER OR SISTER) 10 NEPHEW OR NIECE 11 COUSIN 12 GRANDCHILD 13 OTHER RELATIVE OR IN-LAW 14 NON-RELATIVE 15 OTHER (SPECIFY) 96
F8. What is (her/his) date of birth?	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated	|___|___|/|___|___|/|___|___| MONTH DAY YEAR GO TO F10 Age will be calculated
F9. How old is (he/she)?	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|	A. YEARS |___|___| B. MONTHS |___|___|
IF AGE IS AGE 5-18, ASK F10; OTHERWISE, SKIP TO F12. F10. Is [name] currently attending school?	YES 1 NO 2 (GO TO F12)	YES 1 NO 2 (GO TO F12)	YES 1 NO 2 (GO TO F12)
F11. What grade is [name] attending?	|___|___| GRADE OR PRESCHOOL 13 KINDERGARTEN 14 ELEMENTARY 15 MIDDLE 16 HIGH SCHOOL 17 IN COLLEGE 18 UNGRADED 19	|___|___| GRADE OR PRESCHOOL 13 KINDERGARTEN 14 ELEMENTARY 15 MIDDLE 16 HIGH SCHOOL 17 IN COLLEGE 18 UNGRADED 19	|___|___| GRADE OR PRESCHOOL 13 KINDERGARTEN 14 ELEMENTARY 15 MIDDLE 16 HIGH SCHOOL 17 IN COLLEGE 18 UNGRADED 19
F12. Did [name] live with you in [application month]?	YES 1 NO 2	YES 1 NO 2	YES 1 NO 2
	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)	(GO TO NEXT PERSON)

BOX 8

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

ASK OF EVERYONE

F13. You have just told me that [number of persons on household roster] person(s) live with you. This includes [names of all reported persons]. Just to confirm, have you told me about everyone who lives with you, including babies, small children, people who are not related to you and people who are temporarily away?

YES 1

NO 2 (RETURN TO F5 AND ADD NAMES TO THE HOUSEHOLD ROSTER)

F14. For this next question, do not include temporary visitors. Did anyone live with you in this household in [application month and year] 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 food program benefits at [Target School].

YES 1 (GO TO F15)

NO 2 (GO TO F18a)

F15. How many other people lived with you in [application month and year]?

|___|

ADDITIONAL HOUSEHOLD MEMBERS

F16. Please tell me the first name(s) of the other (person/people) that lived with you in [application month and year] who no longer live here with you now.

______________________________

NAME OF OTHER PERSON # 1

______________________________

NAME OF OTHER PERSON # 2

______________________________

NAME OF OTHER PERSON # 3

BOX 9

FOR EACH ADDITIONAL HOUSEHOLD PERSON RECORDED IN F16, LOOP BACK TO F5 AND ASK F6 TO F12 FOR EACH NAME. THEN GO TO F17.

ASK F17 TO F19 FOR EACH PERSON LISTED ON ROSTER UNDER AGE 18 OR THE TARGET STUDENT REGARDLESS OF AGE [EXCLUDING FOSTER CHILD].

F17. In [application month and year], did you (or your spouse/partner) pay any household expenses or provide any financial support to [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 AND NOT THE TARGET CHILD REGARDLESS OF AGE .

F18. 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

NO 2 (RETURN TO F5)

NOTE: REPLACED PRIOR F19, F20, and F21 WITH NEW F18A

F18a. In the [application month and year], did you share income or expenses with [Name of each adult household member on the created list in Box 8]?

YES 1

NO 2

REPEAT QUESTION FOR EACH ADULT HOUSEHOLD MEMBER CREATED IN BOX 8.

PROGRAMMER NOTE: IF F18A = 1, ASK INCOME QUESTIONS FOR EACH HOUSEHOLD MEMBER.

NOTE: THERE IS NO QUESTION F19, F20, NOR F21. THEY WERE REPLACED WITH F18A.

F22. ASK F22 ONLY IF ANY NAMED CHILD’S RELATIONSHIP TO THE RESPONDENT IS FOSTER CHILD (F6 = 3)

Who has legal responsibility for [name of foster child]?

SELECT NAME(S) FROM HOUSEHOLD ROSTER (INCLUDE ADULTS DO NOT INCLUDE TARGET STUDENT IF 18 OR OLDER) 1

SOMEONE OUTSIDE THE HOUSEHOLD 2

AN AGENCY 3

OTHER, SPECIFY 96

SECTION G: INCOME AND EARNING SOURCES

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

SOURCES:Now we ask you about sources of income and benefits you and the other members of 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]. We want to assure you that all of your responses are kept strictly private.

BOX 12

CREATE LIST OF ALL PERSONS FROM THE HOUSEHOLD ROSTER WITH A CALCULATED AGE LESS THAN 18 YEARS OF AGE (INCLUDING THE [TARGET STUDENT NAME], REGARDLESS OF AGE), AND REPORTED TO HAVE FINANCIAL SUPPORT FROM PARENT/GUARDIAN.

ASK G1-G6 OF EACH CHILD UNDER THE AGE OF 18 OR THE TARGET STUDENT, REGARDLESS OF AGE, WHO HAD FINANCIAL SUPPORT FROM THE PARENT OR GUARDIAN.

G1. During [application month and year], did ([Target Student Name]/[child’s name]) have any income from employment, Social Security or disability survivors benefits, persons outside the household, a pension, annuity, or trust, or any other source? This is income paid directly to your child, not income that you collect yourself.

YES 1

NO 2

(REPEAT G1 FOR EACH CHILD, AFTER LAST CHILD GO TO BOX 13)

G2. What was the source of that income? SELECT ALL THAT APPLY

PROBE: Were there any other sources of income?

EMPLOYMENT 1 (ASK G3)

SOCIAL SECURITY OR DISABILITY
SURVIVORS’ BENEFITS 2 (ASK G4)

PERSONS OUTSIDE THE HOUSEHOLD 3 (ASK G5)

PENSION, ANNUITY, OR TRUST 4 (ASK G6)

OTHER, SPECIFY 96 (ASK G7)

G3. How much did [Target Student Name] receive in [application month and year] from employment?

$ |___|,|___|___|___|

G4. How much did [Target Student Name] receive in [application month and year] in Social Security benefits or disability survivors benefits?

$ |___|,|___|___|___|

G5. How much did [Target Student Name] receive in [application month and year] from persons outside the household?

$ |___|,|___|___|___|

G6. How much did [Target Student Name] receive in [application month and year] from a pension, annuity, or trust?

$ |___|,|___|___|___|

G7. How much did [Target Student Name] receive in [application month and year] from the other sources?

$ |___|,|___|___|___|

REPEAT G1 TO G7 FOR ALL CHILDREN IN CREATED LIST CREATED IN BOX 12.

BOX 13

CREATE LIST OF PERSONS FROM THE HOUSEHOLD ROSTER MEETING THE FOLLOWING CRITERIA:

AN AGE OF 18 OR OLDER (DO NOT INCLUDE TARGET STUDENT IF 18 YEARS OLD) AND REPORTED TO SHARE INCOME AND EXPENSES WITH RESPONDENT (F18A =1)

INTERVIEWER: ASK THE RESPONDENT TO REFER TO THE INCOME WORKSHEET AS A REFERENCE SO THEY CAN FOLLOW ALONG AND SELECT INCOME SOURCES.

G8_INTRO. Please refer to the household income worksheet that shows the list of income sources as we work through the next set of questions.

CONTINUE 1

G8. Do you have the income worksheet handy, even if you have not completed it?

YES 1

NO 2

G8a. INTERVIEWER: IS RESPONDENT ABLE TO TELL THE INCOME SOURCE NUMBER FROM EITHER THE INCOME WORKSHEET FOR [RESPONDENT/PERSON NAME]?

YES 1

NO 2 CONTINUE TO G9

ASK G8B FOR ALL NAMES ON CREATED LIST IN BOX 13, STARTING WITH RESPONDENT.

G8b. Based on your worksheet, please tell me the numbers that correspond to each income source or benefits payments that [you/Target Person Name] received during [application month and year].

INTERVIEWER PROBE: Did [you/Target Person Name] receive income from any other source that you haven’t mentioned or that wasn’t listed as an option on the worksheet?

ASK UNTIL RESPONDENT CONFIRMS THERE IS NO OTHER SOURCE OF INCOME OR BENEFITS FOR RESPONDENT/PERSON. IF YES, SPECIFY AND RECORD. THIS SOURCE WILL BE INCLUDED IN SECTION H.

PROGRAMMER NOTE: ALLOW UP TO 10 INCOME/BENEFITS SOURCES PER PERSON.

INTERVIEWER: CHECK THE BOX ASSOCIATED WITH EACH SOURCE TYPE FOR HOUSEHOLD INCOME AND BENEFIT PAYMENT TYPE REPORTED BY THE RESPONDENT

☐ 01-Paid work

☐ 02-Unemployment

☐ 03-Worker’s compensation

☐ 04-Strike benefits

☐ 05-Social Security/ Railroad Retirement Benefits

☐ 06-Private or public pension, annuity, survivor’s benefits

☐ 07-Military cash subsidies (not combat pay)

☐ 08-Veteran’s benefits

☐ 09-Government disability benefits or Supplemental Security Income (SSI)

☐ 10-Private disability benefits

☐ 11-Alimony payments

☐ 12-Child support payments

☐ 13-Interest, dividends, capital gains, trusts, estates, 401k distributions, or investment income

☐ 14-Rental income from others

☐ 15-Profit or loss from nonfarm business

☐ 16-Profit or loss from farm business

☐ 17-Financial aid to college students (not including tuition, books, & fees)

☐ 18- Regular payments/withdrawals from awards or settlements

☐ 19-Regular cash payments from persons outside the household

☐ 20-Net royalties or one-time prize winnings

☐ 21-General assistance from state or local government (not including TANF or SNAP)

SOURCE 22 WAS REMOVED

☐ 23-Federal Black Lung benefits

☐ 24-Another kind of public assistance. Do not include WIC, SCHIP, SNAP, TANF,FDPIR, Medicaid, or foster care subsidies. SPECIFY

PROGRAMMER NOTE: IF G8A = 1 (YES), SKIP G9 THROUGH G33, OTHERWISE ASK G9-G33 ONE QUESTION AT A TIME.

Q#	During the [application month and year], did (you/[person’s name]) …	Responses
G9	[SOURCE 1] …work at a job for pay? PROGRAMMER NOTE G8: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 01 IS SELECTED in QG8b PROBE: 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. If you have your own business, this only includes the salary you pay yourself as personal income or regular earnings, not any business profits or losses. We will ask about that later.	YES 1 NO 2
INTRO TO NEXT SERIES OF QUESTIONS: The next questions are about other kinds of income (you/[person’s name]) may have received during [application month and year]. Did (you/[person’s name])…
G10	[SOURCE 2] …receive income from unemployment compensation? PROGRAMMER NOTE G9: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 02 IS SELECTED in QG8b	YES 1 NO 2
G11	[SOURCE 3] …receive income from worker’s compensation? PROGRAMMER NOTE G10: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 03 IS SELECTED in QG8B	YES 1 NO 2
G12	[SOURCE 4] …receive income from strike benefits? PROGRAMMER NOTE G11: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 04 IS SELECTED in QG8B	YES 1 NO 2
G13	[SOURCE 5] …receive income from Social Security or railroad retirement benefits? PROGRAMMER NOTE GF12: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 05 IS SELECTED in QG8B	YES 1 NO 2
G14	[SOURCE 6] …receive income from private or public pensions, annuities, or survivor’s benefits? PROGRAMMER NOTE G13: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 06 IS SELECTED in QG8B	YES 1 NO 2
G15	[SOURCE 7] …receive military cash benefits such as housing, food, or clothing allowances? PROBE: Include Military housing allowance if the household lives off base Cash value allowances for off-base housing, food, or clothing (including Basic Allowance for Housing {BAH}) If the service member is deployed, the portion that is made available by them or on their behalf to the household as income. Do not include: Basic pay and cash bonuses Military housing allowance if household lives on base or in military privatized housing Payments from the Family Subsistence Supplemental Allowance (FSSA). Combat Pay resulting from deployment PROGRAMMER NOTE G14: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 07 IS SELECTED in QG8B	YES 1 NO 2
G16	[SOURCE 8] …receive income from Veteran’s benefits? PROGRAMMER NOTE G15: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 08 IS SELECTED in QG8B	YES 1 NO 2
G17	[SOURCE 9] …receive government disability benefits or Supplemental Security Income (SSI) benefits? PROGRAMMER NOTE G16: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 09 IS SELECTED in QG8B	YES 1 NO 2
G18	[SOURCE 10] …receive income from private disability benefits? PROGRAMMER NOTE G17: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 10 IS SELECTED in QG8B	YES 1 NO 2
G19	[SOURCE 11] …receive alimony payments? PROGRAMMER NOTE G18: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 11 IS SELECTED in QG8B	YES 1 NO 2
G20	[SOURCE 12] …receive child support payments? PROGRAMMER NOTE G19: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 12 IS SELECTED in QG8B	YES 1 NO 2
G21	[SOURCE 13] …receive income from interest, dividends, capital gains, trusts, estates, 401K distributions, or other investments? PROGRAMMER NOTE G20: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 13 IS SELECTED in QG8B	YES 1 NO 2
G22	[SOURCE 14] …receive rental income, that is, income from others in the form of rent? PROGRAMMER NOTE G21: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 14 IS SELECTED in QG8B	YES 1 NO 2
G23	[SOURCE 15] …receive profit or loss from (your/their) own nonfarm business, partnership, or professional practice? PROGRAMMER NOTE G22: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 15 IS SELECTED in QG8B PROBE: This is profit or loss is separate from the salary you pay yourself as personal income or regular earnings from the business.	YES 1 NO 2
G24	[SOURCE 16] …receive profit or loss from (your/their) own farm business? PROGRAMMER NOTE G23: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 16 IS SELECTED in QG8B	YES 1 NO 2
G25	[SOURCE 17] …receive financial aid to college students, including money used for room and board? This does NOT included money used for tuition, books, or fees, Pell Grants, Supplemental Education Opportunity Grants, State Student Incentive Grants, National Direct Student Loans, PLUS Loans, College Work Study, or Byrd Honor Scholarshiop Programs. PROGRAMMER NOTE G24: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 17 IS SELECTED in QG8B	YES 1 NO 2
G26	[SOURCE 18] …receive regular payments or withdrawals from awards or settlements? PROGRAMMER NOTE G25: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 18 IS SELECTED in QG8B PROBE: Include income from legal settlements, inheritance, prize winnings, or bonuses.	YES 1 NO 2
G27	[SOURCE 19] …receive regular contributions or support from persons outside the household, for example, cash gifts or other financial assistance from friends or family? PROGRAMMER NOTE G26: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 19 IS SELECTED in QG8B	YES 1 NO 2
G28	[SOURCE 20] …receive any other income, such as net royalties or one-time prize winnings? PROGRAMMER NOTE G27: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 20 IS SELECTED in QG8B	YES 1 NO 2
G29	[SOURCE 21] …receive general assistance benefits from state or local government, such as state disability assistance or general relief programs? Please do not include TANF or SNAP benefits. PROGRAMMER NOTE G28: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 21 IS SELECTED in QG8B	YES 1 NO 2
	G30 WAS REMOVED.
G31	[SOURCE 23] …receive federal black lung benefits? PROGRAMMER NOTE G30 AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 23 IS SELECTED in QG8B	YES 1 NO 2
G32	[SOURCE 24] …receive any other kind of state or local public assistance? Do NOT include WIC, SCHIP, TANF, SNAP, Medicaid, or FDPIR benefits, or foster care subsidies. PROGRAMMER NOTE G31: AUTOMATICALLY SET RESPONSE TO 1 YES IF INCOME SOURCE 24 IS SELECTED in QG8B	YES 1 NO 2
G33	IF QG32 IS YES, ASK: What other kind of public assistance did (you/person’s name]) receive during [application month and year]? IF QG32 IS NO: GO TO SECTION H.	SPECIFY: _______________

INTERVIEWER:

CONFIRM THAT REPORTING IS COMPLETE BY PROBING:

IS THERE ANY OTHER SOURCE OF INCOME THAT WE HAVE NOT DISCUSSED? 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.

SECTION H: INCOME AND EARNING AMOUNTS

Section H records and documents all income sources in the application month for all incomes and benefits reported in Section G.

BOX 16

CREATE LIST OF ALL RESPONDENTS AGE 18 AND OLDER WITH AT LEAST ONE SOURCE OF INCOME OR BENEFITS AS REPORTED IN SECTION G.

H INTRO1: Next, I would like to ask you about the amount 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 that would help with this section are:

• check stubs,

• paystubs,

• 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: ASK THE RESPONDENT IF THEY HAVE DOCUMENTATION TO REVIEW WHILE ANSWERING QUESTIONS. WAIT FOR RESPONDENT TO COLLECT DOCUMENTS THEN CONTINUE ON TO ASK INCOME AND EARNING AMOUNTS.

INTERVIEWER: IF RESPONDENT IS USING INCOME DOCUMENTATION, INSTRUCT RESPONDENT TO TURN THE VIDEO CAMERA ON SO YOU CAN VERIFY THE INFORMATION THROUGHOUT THE SECTION. YOU MAY NEED THEM TO HOLD THE DOCUMENT CLOSE TO THE SCREEN FOR YOUR REVIEW.

ASK H1-H11 FOR EACH ADULT HOUSEHOLD MEMBER WHO HAD INCOME FOR A PAID JOB (SOURCE #1). ELSE GO TO BOX 18.

H_INTRO2: You just told me that (you/[person’s name]) had earnings from paid jobs during [application month and year]. Let’s work together, using the documentation you have available, to document the total pay received.

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 during [application month and year]. The amount I need is the gross or total pay, that is before taxes and other deductions, not the amount that was brought home.

• Please include tips, commissions, 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 the [application month and year].

How much did (you/[person’s name]) earn from a paid job during [application month and year]?

IF APPROPRIATE, ADD: We can probably get that amount from the earnings statement.

IF NEEDED, ADD: Do you have an earnings statement?

IF DOCUMENTATION IS NOT AVAILABLE, ADD: Your best estimate is fine.

$ |___|___|,|___|___|___|

H2. How often are earnings from this job 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 96 (GO TO H4)

H20S. HOW OFTEN ARE THESE EARNINGS PAID TO [PERSON’S NAME]?

IF H2=1 use “hours”, “did you/did PERSONS NAME” and “work”

IF H2 = 2 use “days” “did you/PERSONS NAME” and “work”

IF H2 =3, 4 or 5 use “times” “were you/was PERSONS NAME” and “paid”

H3. How many [hours/days/times] (were you/was [person’s name]) (work/paid) during [application month and year]. Your best estimate of the [hours/days/times] worked is fine. IF APPROPRIATE, ADD: If it is easier, tell me the number of [hours/days] worked weekly.

INTERVIEWER: IF WEEKLY HOURS/DAYS WORKED IS REPORTED RECORD NUMBER REPORTED AND ADD A REMARK (F9).

INTERVIEWER: IF RESPONDENT ANSWERS DON’T KNOW, A COMMENT MUST BE ENTERED FOR CLARIFICATION.

|___|___|

HOURS WORKED/DAYS WORKED/TIMES PAID

H4. INTERVIEWER: WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT THIS PERSON’S EARNINGS FROM A PAID JOB?

YES 1

NO 2 (GO TO H11)

H5. INTERVIEWER: WHAT TYPE OF DOCUMENT WAS DISPLAYED? (CODE ALL THAT APPLY.)

CHECK STUB OR PAY STUB 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

W2 FORM……………………………………8

BANK STATEMENT……………………….. 9

OTHER, SPECIFY 96

H5OS. SPECIFY THE TYPE OF DOCUMENT

__________________________

H6. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

H7. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___|___|,|___|___|___|

H8. DOES THE PAY STATEMENT REFLECT EARNINGS DURING [APPLICATION MONTH], THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

[APPLICATION MONTH] 1 (GO TO H11)

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS PRIOR TO [APPLICATION MONTH] 5

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 income reported in [application month and year]?

IF NEEDED, ADD: I am asking you to compare the income you just reported for this job 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 during [application month and year]?

$ |___|___|,|___|___|___|

H11. Did (you/[person’s name]) have income from any other paid jobs during [application month and year]?

YES 1 (GO TO BOX 17)

NO 2 (GO TO BOX 18)

BOX 17

REPEAT QUESTIONS H1 TO H11 IN A LOOP FOR EVERY JOB UNTIL RESPONSE TO H11 = 2 (NO).

BOX 18

ASK H12-H20 ABOUT ALL OTHER REPORTED SOURCES OF INCOME FOR EACH ADULT PERSON 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 PERSON BEFORE CONTINUING TO ASK THE SAME SERIES FOR THE NEXT ADULT.

H12_INTRO. Previously, you told me about some other sources of income that you and other persons in your household received during [application month and year]. 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 [other income source from G8], during [application month and year]?

PROBE: If income is received on a yearly or quarterly basis, use your best estimate for what amount it would be on a monthly basis.

INTERVIEWER: IF INCOME IS NOT A DIRECT PAYMENT, SUCH AS A SUBSIDY, THE RESPONDENT SHOULD PROVIDE THEIR BEST ESTIMATE OF THE DOLLAR VALUE OF THE SUBSIDY ON A MONTHLY BASIS.

IF APPROPRIATE, ADD: We can probably get this this amount from the payment statement. Do you have a benefits statement ?

OR ADD: Your best estimate is fine.

$ |___|___|,|___|___|___|

FILLS FOR INCOME SOURCES

2= Unemployment

3= Workers Compensation

4=Strike Benefits

5=Social Security or Railroad Retirement Benefits

6= Private or Public Pensions, Annuties, or Survivor’s Benefits

7=Military Cash Benefits

8=Veteran’s Benefits

9= Government Disability Benefits or Supplemental Security Income (SSI)

10= Private Disability Benefits

11= Ailmony Benefits

12= Child Support Payments

13= Interest, dividends, capital gains, trusts, estates, 401K disbursements, or investment Income

14= Net rental income

15= Profit or loss from Nonfarm business, partnership, or professional practice

16= Profit or loss from a farm business

17=Financial aid to college students, not including tuition, books, and fees

18= Regular payments or Withdrawals from awards or settlements

19= Regular cash payments from persons outside the household

20= Other income such as Net Royalties or one-time prize winnings.

21= General assistance benefits from state or local government (not including TANF or SNAP)

23= Federal Black Lung Program

24= Other public benefits (not including WIC, SCHIP,TANF, SNAP, FDPIR, Medicaid, or foster care subsidies)

H13. How often did (you/[person’s name]) receive [other income source from G8]?

WEEKLY 3 (GO TO H13A)

EVERY 2 WEEKS (BI-WEEKLY) 4 (GO TO H13A)

TWICE A MONTH 5 (GO TO H13A)

MONTHLY 6 (GO TO H14)

QUARTERLY 7 (GO TO H14)

ANNUALLY 8 (GO TO H14)

OTHER, SPECIFY 96 (GO TO H14)

H13a. How many times (did you/did [person’s name]) receive a payment. Your best estimate is fine.

.

|___|___|

TIMES PAID

H14. INTERVIEWER: ASK RESPONDENT TO DISPLAY INCOME DOCUMENTION. WAS DOCUMENTATION AVAILABLE TO PROVIDE DETAILS ABOUT [OTHER INCOME SOURCE FROM G8]?

YES 1

NO 2 (GO TO BOX 18)

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

W2 FORM……………………………………6

BANK STATEMENT ……………………….7

OTHER, SPECIFY 96

H15OS.SPECIFY THE TYPE OF DOCUMENT?

____________________________

H16. INTERVIEWER: WHAT WAS THE PERIOD ENDING DATE ON THE DOCUMENT?

|___|___| / |___|___| / |___|___|

MONTH DAY YEAR

INTERVIEWER: KEY VALID DATE IN MMDDYYY FORMAT

INTERVIEWER: END DATE NOT FOUND ON DOCUMENT ENTER DON’T KNOW (F5)

H17. INTERVIEWER: RECORD THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.

$ |___||___|___|,|___|___|___|

H18. DOES THE DOCUMENT REFLECT PAYMENT DURING THE [APPLICATION MONTH], THE CURRENT MONTH, CURRENT YEAR OR ANOTHER TIME PERIOD?

[APPLICATION MONTH] 1 (GO TO BOX 19)

CURRENT MONTH 2

BETWEEN [APPLICATION MONTH] AND CURRENT MONTH 3

1 TO 3 MONTHS PRIOR TO [APPLICATION MONTH] 4

MORE THAN 3 MONTHS SINCE [APPLICATION MONTH] 5

CURRENT YEAR…………………………………………………………6

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 [application month and year]?

IF NEEDED, ADD: I am asking you to compare the payment amount on this statement to the payment from [other income source from G8] 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 19)

LESS 2

MORE 3

H20. What is your best estimate of the amount (you/[person’s name]) received from this [other income source from G8] during [application month and year]?

$ |___|___|,|___|___|___|

INTERVIEWER: RECORD AMOUNT TO NEAREST WHOLE DOLLAR.

BOX 19

REPEAT THE LOOP OF H12 THROUGH H20 TO ASK ABOUT EACH ADULT PERSON WITH AT LEAST ONE REPORTED SOURCE OF INCOME OR BENEFIT.

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 20

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.

ASKED TO ALL RESPONDENTS

I1. The computer just added up all the income sources you told me about and the total household income for all household members in [application month and year] (including the income of people no longer living in your household) is [calculated total from all sources]. Does that sound about right for your gross monthly income, that is, your pay before taxes and other deductions, not the amount that was brought home?

YES 1 (GO TO I4)

NO 2 (GO TO I2)

I2. Let’s review each income source and amount 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 [application month and year] 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)

ASKED TO ALL RESPONDENTS

I4. Was the [total from all sources listed in section F and G] we just recorded for your household income in [application month and year] a usual amount, or was it more than 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

LESS THAN AVERAGE 3

I5. Since the total amount we just recorded for your household in [application month and year] is not the usual amount, how much do you expect the usual amount for your monthly household income to be over this school year?

$ |___|___|___|,|___|___|___|

SECTION J: DEMOGRAPHIC CHARACTERISTICS

Section J is a series of demographic questions.

PROGRAMMER NOTE: IF E4B=1, SKIP J1

J_INTRO. The next set of questions will gives us background information on the people completing this survey.

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

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 96

J3. Do you consider yourself to be Hispanic or of Latino origin?

PROBE: That is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 2

J4. Which, if any, of the following racial group or groups do you identify with: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White? (MARK 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…………………………………………………………………. 96 (J40S)

PROBE: Do you identify with any racial group or groups I didn’t mention?

J40S. WHAT RACIAL GROUP?

____________________________

THERE IS NO QUESTION J5.

J6. What is the primary language spoken in your household?

English……………………………………… 1

Spanish 2

Chinese (e.g. Mandarin or Cantonese) 3

French 4

Tagalog 5

Vietnamese 6

Korean 7

Arabic 8

Russian 9

Other (specify) _______________ 96 (J60S)

J60S. WHAT IS THE PRIMARY LANGUAGE SPOKEN IN THE HOUSEHOLD?

____________________________

J9_INTRO. The next questions are about [Target Student Name].

J9. Do you consider [Target Student Name] to be of Hispanic or of Latino origin?

PROBE: This is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.

HISPANIC OR LATINO 1

NOT HISPANIC OR LATINO 2

J10. Which, if any, of the following racial group or groups would you consider [Target Student Name] to identify with: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White? (MARK 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 96 (J10OS)

J10OS. WHAT RACIAL GROUP?

____________

SECTION K: CLOSE OUT AND FUTURE CONTACT

This final section K closes out the survey and provides information for the payment of the respondent. In addition, respondents may be asked if they are willing to be considered for a future interview to repeat the survey process, including income verification, in-person. If they are willing, contact information is collected.

INTERVIEWER: IF RESPONDENT DID NOT HAVE INCOME DOCUMENTATION OR BENEFITS DOCUMENTATION, ASK IF THEY WANT TO PROVIDE DOCUMENTATION FOR VERIFICATION OF THEIR REPORTE BENEFITS OR INCOME. IF NECESSARY, REMIND THEM OF THE ADDITIONAL INCENTIVE.

IF YES, AFTER THE INTERVIEW IS COMPLETE, FOLLOW PROTOCOL FOR PROVIDING INTRUCTIONS ON SENDING INCOME DOCUMENTATION TO HOME OFFICE VIA SECURE EMAIL OR SECURE TEXT.

IF NO, PLEASE PROCEED.

K1. INTERVIEWER: DID RESPONDENT PROVIDE AT LEAST ONE SOURCE OF INCOME OR BENEFITS DOCUMENTATION?

YES 1 (GO TO K5)

DOES NOT WANT TO PROVIDE 2 (GO TO K5)

WILL SEND …………………….. 3 (GO TO K2)

K2. Would you like to send your income documentation now?

YES 1 (GO TO K4)

NO 2 (GO TO K3)

K4. INTERVIEWER: USE “INSTRUCTIONS TO SEND INCOME DOCUMENTATION AFTER SURVEY” TO GUIDE RESPONDENT THROUGH PROCESS OF REDACTING PERSONAL INFORMATION AND SENDING INCOME DOCUMENTATION BY TEXT OR EMAIL. CONTINUE TO K5.

K3. We would like to provide you with instructions on how to send the income documentation that you used to assist you during the survey, for verification of the benefits or income questions. This information will only be used for the purposes of communicating with you about the income documentation, and will not be used for any other reason. Do you have an email address?

YES, 1

NO EMAIL ADDRESS GIVEN 2 (GO TO K5)

K3a. What is your email address?

_______________________________

ENTER EMAIL ADDRESS

INTERVIEWER: CONFIRM SPELLING OF EMAIL ADDRESS BEFORE MOVING ON.

K4. Thank you. We will email you the instructions for sending your income documentation within the next 2 business days. Your study ID is [Respondent Unique Study ID].

K5. This is the end of the interview. Thank you very much for participating in our study. You will now choose how to receive your ($40 for completing the survey/$60 for completing the survey and providing income documentation/$40 for completing the survey and $20 when we receive your income documentation).

WAS INCENTIVE PAYMENT ACCEPTED?

YES 1

NO 2

INCENTIVE PAYMENT AMOUNT:

$40.00 for Interview............................................................. 1

$60.00 for Interview and Income Documentation................. 2

TIME INTERVIEW ENDED: | | |:| | | AM 1

HOUR MINUTE PM 2

K6a. You can choose to receive your incentive payment, which is a Visa® electronic gift card, by email or by mail. How would you like to receive your incentive payment?

Email 1 (GO TO K6B)

Mail 2 (GO TO K6C)

K6b. EMAIL: In order to send your Visa® electronic gift card, we need your email address.Please note that your incentive payment will only be sent to the email address you provide. What is the email address where you woud like to receive your Visa® electronic gift card?

_______________________________

ENTER EMAIL ADDRESS

INTERVIEWER: CONFIRM SPELLING OF EMAIL ADDRESS BEFORE MOVING ON. (GO TO K6E)

K6c. MAIL: In order to send your Visa® gift card by mail, we need your mailing address. Please note that your incentive payment will only be sent once, to the mailing address you provide. What is your mailing address?

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

__________ _____________ _________

ENTER CITY ENTER STATE ENTER ZIP CODE

INTERVIEWER: CONFIRM FULL MAILING ADDRESS BEFORE MOVING ON. (GO TO K6D)

K6d. (FOR MAILED VISA GIFT CARD) INTERVIEWER: SCAN/ENTER THE VISA GIFT CARD INFORMATION INTO THE SYSTEM.

PROGRAMMER: DISPLAY THE CASE ID NUMBER

K6e. INTERVIEWER:

• MAILED VISA GIFT CARD: FOLLOW THE PROTOCOL FOR GIFT CARD ACTIVATION

• E-VISA GIFT CARD: FOLLOW PROTOCOL TO PROVIDE INSTRUCTIONS TO RESPONDENT

BOX 21

CONTINUE TO K7, IF PROMPTED, IF RESPONDENT’S SFA WAS SELECTED FOR SUB STUDY. OTHERWISE SKIP TO K16.

K7. To help us improve the quality of information we collect on this survey, we would like to invite you to participate in a follow-up interview sometime in the next two months. This follow-up interview would be conducted in-person, either at your home or at a convenient location for you. During the follow-up interview, the interviewer will ask to see your income documentation if you have it available. You would receive an additional $40 for completing the in-person survey, plus an additional $20 for showing us your income documentation. Are you interested in participating?

YES 1

NO 2 (GO TO K16)

K8. Thank you. A member of the research team will contact you to schedule the appointment for the in person survey. I’d like to confirm your contact information. The address I have on file for you is (INSERT ADDRESS). Is that the best location to conduct the survey?

YES 1 (GO TO K10)

NO 2

K9. Please provide an address for the interviewer to visit for the survey. This could be at your home, or a different location if you choose. If you need to change the address prior to the visit, that is ok, too.

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

__________ _____________ _________

ENTER CITY ENTER STATE ENTER ZIP CODE

K10. I have your phone number as (INSERT PHONE NUMBER). Is that correct?

YES 1

NO 2 (GO TO K12)

K11a. If this is a cell phone, would you be comfortable with receiving text message reminders about your survey interview?

YES 1 (GO TO K13)

NO 2 (GO TO K13)

N/A, NOT A CELL PHONE 3 (GO TO K13)

K12. Could you please give me a phone number where we can reach you?

ENTER PHONE NUMBER

K12a. If this is a cell phone, would you be comfortable with receiving text message reminders about your survey interview?

YES 1

NO 2

N/A, NOT A CELL PHONE 3

K13. What is another phone number where we may reach you?

(GO TO K13a)

ENTER PHONE NUMBER

NO SECOND NUMBER GIVEN 1 (GO TO K14)

K13a. If this is a cell phone, would you be comfortable with receiving text message reminders about your survey interview?

YES 1

NO 2

N/A, NOT A CELL PHONE 3

K14. It would also help to have an email address where we can contact you about your follow-up interview. This information will only be used for the purposes of communicating with you about this follow-up interview and will not be used for any other reason. Do you have an email address? (IF YES:) What is your email address?

YES, 1

NO EMAIL ADDRESS GIVEN 2

K15. Do you have any questions at this time?

YES [ANSWER QUESTIONS] 1

NO 2

K16. Thank you very much for participating in the National School Meals Study.

Authority: This information is being collected under the authority of the Healthy, Hunger-Free Kids Act of 2010 (P. L. 111-296), Section 305.

Purpose: The Food and Nutrition Service (FNS) is collecting this information to assess improper payments made in the National School Lunch Program (NSLP) and School Breakfast Program (SBP).

Routine Use: The records in this system may be disclosed to private firms that have contracted with FNS to collect, aggregate, analyze, or otherwise refine records for the purpose of research and reporting to Congress and appropriate oversight agencies, and/or departmental and FNS officials.

Disclosure: Disclosing the information is voluntary, and there are no consequences to you as an individual for not providing the information. 

The System of Records Notice for this information collection is USDA/FNS-8, FNS Studies and Reports, which can be located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf (p. 19078).

Authority: This information is being collected under the authority of the Healthy, Hunger-Free Kids Act of 2010 (P. L. 111-296), Section 305.

Purpose: The Food and Nutrition Service (FNS) is collecting this information to assess improper payments made in the National School Lunch Program (NSLP) and School Breakfast Program (SBP).

Routine Use: The records in this system may be disclosed to private firms that have contracted with FNS to collect, aggregate, analyze, or otherwise refine records for the purpose of research and reporting to Congress and appropriate oversight agencies, and/or departmental and FNS officials.

Disclosure: Disclosing the information is voluntary, and there are no consequences to you as an individual for not providing the information. 

The System of Records Notice for this information collection is USDA/FNS-8, FNS Studies and Reports, which can be located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf (p. 19078).

This information is being collected to provide the Food and Nutrition Service with key information on the annual error rates and improper payments for the school meal programs. This is a voluntary collection and FNS will use the information to examine school meal error rates and inform future APEC studies. This collection requests personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0530. The time required to complete this information collection is estimated to average 0.75 hours (45 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. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0530). Do not return the completed form to this address.

Page 1 of 84