Individuals or Households Respondents

OMB Number: 0584-0674

Expiration Date: 09/30/2025

Appendix C.1. Household Survey Instrument in English

Your household has been selected to participate in an important study about health and well-being in Puerto Rico. The purpose of this study is to learn more about the kinds of resources that households have and additional resources they may need to lead healthy lives. The survey includes questions about shopping and eating habits, community programs available in your neighborhood, and coping with natural disasters.

Who should complete this survey? A household member who is—

• At least 18 years of age

• Able to answer questions about household grocery shopping, food, and expenses

Risks and privacy

Some of the questions in the survey are potentially sensitive, but your answers will be kept private. We will combine all responses and report them as overall findings. These findings may be shared with the research community at large to advance science and health. We will remove any personal information so that no survey respondents can be identified from the information we share.

Study costs and compensation

There is no cost to you to participate, apart from the time you spend responding to the survey. We expect this survey to take about 40 minutes.

When we receive your survey, we will send you a $40 gift card to thank you for your time.

Your participation can help improve programs designed to promote health and well-being among Puerto Rico residents.

Voluntary participation

Your participation is entirely voluntary. We hope you will respond, but you may skip a question or discontinue the survey at any time.

Participation in the survey will not affect any benefits you might receive from Administración de Desarrollo Socioeconómico de la Familia.

Questions

If you have questions about the study or your rights as a research participant, please call [local number for Estudios Técnicos].

Public Burden Statement

This information is being collected to assist the Food and Nutrition Service (FNS) in understanding food security status and economic well-being among Puerto Rico residents. This is a voluntary collection. FNS will use the information as a baseline for future assessments of food security and the Nutrition Assistance Program, particularly in the context of natural disasters. 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 0584-0674. The time required to complete this information collection is estimated to average 40 minutes per response, including the time for reviewing instructions 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, Alexandria, VA 22314. ATTN: PRA (0584-0674). Do not return the completed form to this address.

Privacy Act Statement

Authority: Section 105 of the Additional Supplemental Appropriations for Disaster Relief Act, 2019, P.L. 116–20, authorizes collection of the information on this application.

Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration of the Nutrition Assistance Program.

Routine Use: Information may be disclosed for any of the routine uses listed in the published System of Record notice titled FNS-8 USDA/FNS Studies and Reports published in the Federal Register April 25, 1991, Volume 56, Number 80 (pages 19078–19080).

Disclosure: Furnishing the information on this form is voluntary. There are no penalties for nonresponse.

1. Grocery Shopping

When answering these questions, please think about your household. By household, we mean people who live with you and with whom you purchase and prepare food.

If you purchase foods and prepare meals for yourself only, please answer only for yourself.

A.1. Are you the primary shopper for your household, that is, are you the person who usually buys most of the groceries?

[ ] Yes

[ ] No

A.2. Where do you (or the primary shopper) buy most of your groceries?

MARK ONE

[ ] Supermarket (e.g., Pueblo, Econo, Amigo, Selectos)

[ ] Super store (e.g., Walmart)

[ ] Warehouse club store (e.g., Sam’s Club, Costco)

[ ] Colmado, local or independent grocery store

[ ] Convenience store, corner store, or dollar store

[ ] Local street markets or street vendors

[ ] Online retailers

[ ] Other store

[ ] Don’t know

A.3. In a typical month, how often do you (or the primary shopper) shop for food at this store?

[ ] More than once a week

[ ] Once a week

[ ] Once every 2 weeks

[ ] About once a month or less

[ ] Don’t know

A.4. How much time does it usually take you (or the primary shopper) to get to this store?

[ ] Less than 10 minutes

[ ] 10 to 20 minutes

[ ] 21 to 30 minutes

[ ] More than 30 minutes

[ ] Don’t know

A.5. How do you (or the primary shopper) usually get to this store?

MARK ONE

[ ] In my (or the primary shopper’s) car

[ ] In a car that belongs to someone I (or the primary shopper) live with

[ ] In a car that belongs to someone who lives elsewhere

[ ] Walk

[ ] Ride bicycle

[ ] Bus, subway, or other public transit

[ ] Taxi or other paid driver

[ ] Someone else delivers groceries

[ ] Some other way

[ ] Don’t know

A.6. How often do you (or the primary shopper) usually buy groceries at any other stores?

[ ] Do not usually buy groceries at other stores

[ ] More than once a week

[ ] Once a week

[ ] Once every 2 weeks

[ ] About once a month or less

[ ] Don’t know

A.7. Thinking about all the stores where you (or the primary shopper) shop for groceries, how would you describe the selection of foods in each category listed below?

FOR EACH ITEM BELOW (a–l) MARK ONE	Poor	Average	Good	Don’t know/don’t buy
Fresh fruits
Frozen fruits
Canned fruits
Dried fruits
Fresh vegetables
Frozen vegetables
Canned vegetables
Dried or canned beans
Breads, rice or other grains
Dairy products such as milk, cheese, or yogurt
Meats, such as beef, chicken, or pork
Seafood

A.8. Thinking about all the stores where you (or the primary shopper) shop for groceries, how easy is it to buy these foods on your budget?

FOR EACH ITEM BELOW (a–l) MARK ONE	Very easy	Easy	Difficult	Very difficult	Don’t know/ don’t eat
Fresh fruits
Frozen fruits
Canned fruits
Dried fruits
Fresh vegetables
Frozen vegetables
Canned vegetables
Dried or canned beans
Breads, rice or other grains
Dairy products such as milk, cheese, or yogurt
Meat, such as beef, chicken, or pork
Seafood

A.9. Is shopping for groceries for your household difficult for any of the following reasons?

Yes	No	FOR EACH ITEM BELOW (a–g) MARK YES OR NO
[ ]	[ ]	a. Distance to the store
[ ]	[ ]	b. Transportation
[ ]	[ ]	c. Store hours
[ ]	[ ]	d. Affordability (food prices)
[ ]	[ ]	e. Physical disability
[ ]	[ ]	f. Amount of time available to shop at the store
[ ]	[ ]	g. Safety concerns (in and around the stores)

A.10. In the past 30 days, about how much money did you/your household spend on food at supermarkets, grocery stores, or other stores that sell food products?

Include in your estimate food purchased with Nutrition Assistance Program (NAP) benefits.

$_______

2. Feeding Your Household

Next are several statements people have made about their food situation. For these statements, please answer whether the statement was often true, sometimes true, or never true for your household in the last 12 months.

B.1. In the last 12 months, we worried whether our food would run out before we got money to buy more. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

B.2. In the last 12 months, the food that we bought just didn’t last, and we didn’t have money to get more. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

B.3. In the last 12 months, we couldn’t afford to eat balanced meals. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

For the following questions, please continue to answer for your household in the last 12 months.

B.4. In the last 12 months, 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, almost every month

[ ] Yes, some months but not every month

[ ] Yes, only 1 or 2 months

[ ] No

B.5. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

[ ] Yes

[ ] No

B.6. In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough money for food?

[ ] Yes

[ ] No

B.7. In the last 12 months, did you lose weight because there wasn’t enough money for food?

[ ] Yes

[ ] No

B.8. In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food?

[ ] Yes, almost every month

[ ] Yes, some months but not every month

[ ] Yes, only 1 or 2 months

[ ] No

If your household does not include children under 18, skip to Section C.

Following are several statements people have made about the food situation of their children. For these statements, please answer whether the statement was often true, sometimes true, or never true in the last 12 months for children under 18 years old living in the household.

Some people may find these questions sensitive. Your answers are private and can help us understand the needs of families in Puerto Rico. We will not share any personal information about you with any agencies, and your answers will not have any impact on assistance you may receive from ADSEF.

B.9. In the last 12 months, we relied on only a few kinds of low-cost food to feed the children because we were running out of money to buy food. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

B.10. In the last 12 months, we couldn’t feed the children a balanced meal because we couldn’t afford it. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

B.11. In the last 12 months, the children were not eating enough because we just couldn’t afford enough food. Was that…

[ ] Often true

[ ] Sometimes true

[ ] Never true

For the following questions, please continue to answer about the last 12 months for any child(ren) under 18 living in the household.

B.12. In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t enough money for food?

[ ] Yes

[ ] No

B.13. In the last 12 months, did any of the children ever skip meals because there wasn’t enough money for food?

[ ] Yes, almost every month

[ ] Yes, some months but not every month

[ ] Yes, only 1 or 2 months

[ ] No

B.14. In the last 12 months, were the children ever hungry, but you just couldn’t afford more food?

[ ] Yes

[ ] No

B.15. In the last 12 months, did any of the children ever not eat for a whole day because there wasn’t enough money for food?

[ ] Yes

[ ] No

3. Coping Strategies, Community Resources, and Your Neighborhood

C.1. In the last 12 months, how often did you or people in your household have to do any of the following things to make your food money go further?

FOR EACH ITEM BELOW (a–j) MARK ONE		Often	Once in a while	Hardly at all	Never/ not an option
a.	Get food you have to replace from family or friends
b.	Borrow money you have to repay from family or friends
c.	Carry or increase credit card debt
d.	Send household members to eat elsewhere
e.	Exchange labor for food
f.	Buy groceries using money set aside for other purposes
g.	Get food from a pantry or soup kitchen
h.	Skip buying medicine or seeking medical care
i.	Delay paying rent/mortgage
j.	Delay paying other bills (utilities, car, credit cards, etc.)

C.2. Does your neighborhood have any of the following places or programs for households that may need help with food or meals?

Yes	No	Don’t know	FOR EACH ITEM BELOW (a–e) MARK YES, NO, OR DON’T KNOW
[ ]	[ ]	[ ]	Food bank or pantry
[ ]	[ ]	[ ]	Free meals served at a shelter, food kitchen, or soup kitchen
[ ]	[ ]	[ ]	Free meals served at a church, community, or senior center
[ ]	[ ]	[ ]	Meals on Wheels or other home delivery meal programs
[ ]	[ ]	[ ]	Food Boxes (e.g., Alimentos para Mi Gente)

C.3. In the last 12 months, have you or anyone in your household visited a food bank, pantry, or similar place to get food for you or your household?

[ ] Yes

[ ] No GO TO C.4

C.3a. Please indicate how much you agree or disagree with each of the following statements.

Overall, places in my neighborhood that offer help with foods or meals…	Strongly agree	Agree	Neither	Disagree	Strongly disagree
Are easy to get to
Have healthy food
Have staff who treat customers well
Have enough food for all who show up

Please indicate how much you agree or disagree with the following statements about the neighborhood where you live and the people around you.

C.4. People around here are willing to help their neighbors.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.5. This is a close-knit or “tight” neighborhood where people generally know one another.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.6. If I had to borrow $30 in an emergency, I could borrow it from a neighbor.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.7. People in this neighborhood generally don’t get along with one another.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.8. People in this neighborhood can be trusted.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.9. If I were sick, I could count on my neighbors to shop for groceries for me.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

C.10. People in this neighborhood do not share the same values.

[ ] Strongly agree

[ ] Agree

[ ] Neither agree nor disagree

[ ] Disagree

[ ] Strongly disagree

The next questions are about strategies households may use to meet their basic needs after a natural disaster. Natural disasters may include hurricanes, tropical storms, drought, wildfires, and earthquakes.

C.11. Have you experienced a natural disaster in Puerto Rico in the last 5 years?

[ ] Yes

[ ] No GO TO C.13

C11.a Please indicate which disaster you most recently experienced.

If you experienced more than one, pick the most recent disaster

[ ] Hurricane Fiona (September 18, 2022)

[ ] Earthquakes (2020)

[ ] Hurricane María (September 20, 2017)

[ ] Hurricane Irma (September 7, 2017)

[ ] Other natural disaster (specify: _________________)

C.12. Thinking about the most recent natural disaster you experienced, did your household do any of the following to obtain needed resources?

Yes	No	FOR EACH ITEM BELOW (a–j) MARK YES OR NO
[ ]	[ ]	Rely on support from a nonprofit (e.g., Red Cross)
[ ]	[ ]	Apply for NAP benefits
[ ]	[ ]	Apply for other forms of government assistance
[ ]	[ ]	Borrow money from family or friends
[ ]	[ ]	Carry or increase credit card debt
[ ]	[ ]	Sell or pawn items
[ ]	[ ]	Look for additional sources of income
[ ]	[ ]	Get a payday loan
[ ]	[ ]	Reduce expenses
[ ]	[ ]	Use savings

The next question is about how your household coped with any financial challenges that resulted from the Coronavirus pandemic (COVID-19).

C.13. As a result of the Coronavirus pandemic (COVID-19), did your household do any of the following to obtain needed resources?

Yes	No	FOR EACH ITEM BELOW (a–j) MARK YES OR NO
[ ]	[ ]	a. Rely on support from a nonprofit (e.g., Red Cross)
[ ]	[ ]	b. Apply for NAP benefits
[ ]	[ ]	c. Apply for other forms of government assistance
[ ]	[ ]	d. Borrow money from family or friends
[ ]	[ ]	e. Carry or increase credit card debt
[ ]	[ ]	f. Sell or pawn items
[ ]	[ ]	g. Look for additional sources of income
[ ]	[ ]	Get a payday loan
[ ]	[ ]	Reduce expenses
[ ]	[ ]	Use savings

4. About You and Your Household

D.1. Including you, how many people currently living in your household are:

[ __ ] Aged 17 years or younger

[ __ ] Between 18 and 59 years

[ __ ] Aged 60 years and older

D.2. In the last 12 months, has there been a change in the number of people living in your household?

[ ] Yes

[ ] No GO TO D.3

D.2a. What caused this change?

MARK ALL THAT APPLY

[ ] Birth of child

[ ] New step, foster, or adopted child

[ ] Marriage, new partner

[ ] Separation or divorce

[ ] Death of a household member

[ ] Boarder moving in

[ ] Family, boarder moving out

[ ] Other

D.3. Which best describes the place where you live?

MARK ONE

[ ] A mobile home (e.g., RV, trailer)

[ ] A one-family house detached from any other house

[ ] A one-family house attached to one or more houses

[ ] A building with two or more apartments

[ ] Other

D.4. Is the place where you live…

MARK ONE

[ ] Owned by you or someone in this household with a mortgage or loan?

[ ] Owned by you or someone in this household free and clear (without a mortgage or loan)?

[ ] Rented?

[ ] Occupied without payment of rent?

D.5. Are there any other households living at your same mailing address? This might include households living in garage or multi-family homes.

[ ] Yes IF YES [ __ ] How many households?

[ ] No

D.6. Do you or any member of your household have access to the internet using a…

Yes	No	FOR EACH ITEM BELOW (a–e) MARK YES OR NO
[ ]	[ ]	Cellular data plan for a smartphone or other mobile device?
[ ]	[ ]	Broadband (high-speed) internet service such as cable, fiberoptic, or DSL service installed in this household?
[ ]	[ ]	Satellite internet service installed in this household?
[ ]	[ ]	Dial-up internet service installed in this household?
[ ]	[ ]	Some other service?

D.7. What language is most commonly spoken in your home?

[ ] Spanish

[ ] English

[ ] Spanish and English are spoken about equally

[ ] A language other than Spanish or English

D.8. Thinking about the person in your household who has completed the most schooling, what is the highest degree or level of school that person completed?

[ ] Less than 12th grade (no high school diploma)

[ ] Regular high school diploma or GED

[ ] 1 or more years of college credit, no degree

[ ] Associate’s degree

[ ] Technical or vocational certificate or diploma

[ ] Bachelor’s degree

[ ] Graduate degree

D.9. Has anyone in your household ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

[ ] No

[ ] Yes, on active duty now or training in the Reserves or National Guard

[ ] On active duty in the past but not now

5. Participation in Federal Programs

The following questions ask about the participation of your household in various Federal programs.

E.1. Have you or anyone in your household received benefits from the Nutrition Assistance Program (NAP) in the last 12 months?

NAP benefits are provided on an electronic debit card called the Tarjeta de la Familia.

[ ] Yes

[ ] No GO TO E.2

E.1.a. During the past 12 months, for how many months did you get NAP benefits?

[ __ ] months

E.1.b. Did you or anyone in your household receive benefits from NAP in [insert month and/or month of 20## -- i.e., months of sample selection]?

[ ] Yes

[ ] No

E.1.c. Do you or anyone in your household currently receive benefits from NAP?

[ ] Yes

[ ] No

E.1.d. Thinking about the last time you received NAP benefits, how much did you receive in benefits?

$______

E.1.e. How many weeks do your monthly NAP benefits usually last?

[ ] 1 week or less

[ ] 2 weeks

[ ] 3 weeks

[ ] 4 weeks

[ ] More than 4 weeks

E.2. In the past 12 months, did anyone in your household receive…

Yes	No	FOR EACH ITEM BELOW (a–j) MARK YES OR NO
[ ]	[ ]	Help from a Government program to pay rent or housing costs
[ ]	[ ]	Help from the Low-Income Home Energy Assistance Program to pay electric, gas, or utility bills (LIHEAP)
[ ]	[ ]	Aid to the Aged, Blind, and Disabled (AABD)
[ ]	[ ]	Social Security Disability Insurance (SSDI)
[ ]	[ ]	Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
[ ]	[ ]	Temporary Assistance for Needy Families (TANF)
[ ]	[ ]	Help paying for childcare from a Government agency
[ ]	[ ]	Free or reduced-cost food at a daycare or Head Start program?
[ ]	[ ]	Free or reduced-cost lunches at school? (Includes grab-and-go meals students could pick up and take home if schools were closed due to a disaster or public health crisis.)
[ ]	[ ]	Free or reduced-cost breakfasts at school? (Includes grab-and-go meals students could pick up and take home if schools were closed due to a disaster or public health crisis.)

6. Household Employment and Finances

The following questions ask about household employment and finances. These responses will only be reported in summary format and will not affect your receipt of any public benefits.

F.1. Including yourself, how many adults aged 18 and older in the household were employed in the last 30 days?

[ __ ] Number of adults employed full time

[ __ ] Number of adults employed part time

[ __ ] No adults were employed

F.2. Has anyone in your household had a change in employment or a change in pay or hours worked at a job in the past 12 months?

[ ] Yes

[ ] No GO TO F.3

F.2a. Was that change because of…

MARK ALL THAT APPLY

[ ] Getting a job

[ ] Losing a job or leaving a job

[ ] Increase in pay or hours

[ ] Decrease in pay or hours

F.3. Are there any 16- or 17-year-old youths in your household?

[ ] Yes

[ ] No GO TO F.4

F.3a. How many youths aged 16 and 17 were employed in the last 30 days?

[ __ ] Number of youths employed full time

[ __ ] Number of youths employed part time

[ __ ] No youths were employed

F.4. Please indicate whether you or anyone in your household received income in the last 12 months from any of the following:

MARK ALL THAT APPLY

[ ] 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

[ ] Any public assistance or welfare payments from the State or local welfare office

[ ] Retirement income, pensions, survivor, or disability income

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

F.5. Which category best describes your total household income last year before taxes or other deductions?

[ ] No income

[ ] $1–$4,999

[ ] $5,000–$9,999

[ ] $10,000-$14,999

[ ] $15,000–$19,999

[ ] $20,000–$24,999

[ ] $25,000–$29,999

[ ] $30,000–$39,999

[ ] $40,000–$49,999

[ ] $50,000–$50,999

[ ] $60,000 or more

F.6. 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

F.7. Please rate the extent to which each of the problems below was a concern for your household in the past 12 months.

FOR EACH ITEM BELOW (a–e) MARK ONE	Not a problem	Mild problem	Moderate problem	Severe problem
a. Ability to pay for utilities (heating/cooling/water)
b. Ability to pay rent or mortgage
c. Ability to pay for cellular or internet service
d. Getting someone to watch over children or other dependents
e. Having reliable, convenient transportation

7. Health and Access to Healthcare

G.1. Please indicate if you or anyone in your household has difficulty with the following activities.

FOR EACH ITEM BELOW (a–f) MARK ONE	No difficulty	Some difficulty	A lot of difficulty	Cannot do at all	Don’t know
Seeing, even if wearing glasses	[ ]	[ ]	[ ]	[ ]	[ ]
Hearing, even if using hearing aid(s)	[ ]	[ ]	[ ]	[ ]	[ ]
Walking or climbing steps	[ ]	[ ]	[ ]	[ ]	[ ]
Remembering or concentrating	[ ]	[ ]	[ ]	[ ]	[ ]
Self-care, such as washing all over or dressing	[ ]	[ ]	[ ]	[ ]	[ ]
Communicating using the language most commonly spoken at home; for example, understanding or being understood	[ ]	[ ]	[ ]	[ ]	[ ]

G.2. Are you or is anyone in your household limited in the kind OR amount of work you (they) can do because of a physical, mental, or emotional problem?

[ ] Yes

[ ] No

[ ] Don’t know

G.3. Do you or does anyone in your household have difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition?

[ ] Yes

[ ] No

[ ] Don’t know

G.4. Including you, are any members of your household currently covered by any of the following types of health insurance or health coverage plans?

Yes	No	Don’t know	FOR EACH TYPE OF COVERAGE (a–e) MARK YES OR NO
[ ]	[ ]	[ ]	Insurance through a current or former employer or union
[ ]	[ ]	[ ]	Medicare, for people 65 and older or people with certain disabilities
[ ]	[ ]	[ ]	Medicaid, Medical Assistance, Children’s Health Insurance Program (CHIP), or any kind of Puerto Rico-sponsored assistance plan based on income or a disability
[ ]	[ ]	[ ]	TRICARE or other military healthcare
[ ]	[ ]	[ ]	Any other type of health insurance or health coverage plan

G.5. In the past 12 months, did anyone in your household have problems paying any medical bills?

[ ] Yes

[ ] No

[ ] Don’t Know

G.6. Thinking about your healthcare experiences over the past 12 months, has medical care been delayed for anyone in the household because of worry about the cost?

[ ] Yes

[ ] No

[ ] Don’t Know

G.7. In the past 12 months, was there any time when anyone in the household needed medical care but did not get it because they couldn’t afford it?

[ ] Yes

[ ] No

[ ] Don’t Know

G.8. In the past 12 months, have you or any members of your household received treatment, counseling, or services because of a problem with alcohol, tobacco, or drug use?

[ ] Yes

[ ] No

[ ] Don’t Know

8. Respondent Demographics

H.1. Are you…

[ ] Between 18–29 years

[ ] Between 30–39 years

[ ] Between 40–49 years

[ ] Between 50–59 years

[ ] 60 or older

H.2. Do you currently describe yourself as…

[ ] Male

[ ] Female

[ ] Transgender

[ ] None of the above

H.3. Are you…

[ ] Married

[ ] Divorced

[ ] Separated

[ ] Widowed

[ ] Never married

H.4. Are you of Hispanic or Latino origin?

[ ] Yes, Puerto Rican

[ ] Yes, other Hispanic or Latino origin

[ ] No

H.5. Are you…

MARK ALL THAT APPLY

[ ] White

[ ] Black or African American

[ ] Asian

[ ] Native Hawaiian or Other Pacific Islander

[ ] American Indian or Alaska Native

[ ] Other

H.6.      Are you a Puerto Rico resident?

[ ] Yes

[ ] No

9. Thank You and Next Steps

Thank you for completing this survey. We will send you a $40 gift card to thank you for your time.

Please let us know where to send $40 for this survey.

Name:

Street address:

City:

State:

ZIP Code:

Please let us know if you are willing to be contacted.

[ ] I agree to be contacted for a follow-up interview in the next month or so if selected. (The interview will take about an hour, and you will receive $50 as a thank-you.)

Home number:

Cell phone number:

Email address:

[ ] I agree to be contacted for additional surveys in the future.

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:

Food Security Status and Well-Being of NAP Participants in Puerto Rico, Appendix C.1 Household Survey Instrument in English C-29