OMB Control No. 0584-0611
Expiration Date: 11/30/2025
Attachment B: Screening Questionnaire
SNAP E&T Marketing Support Participant Focus Groups
Screening Questions
Note: Some questions are to qualify/disqualify participants and others are to track demographics to ensure participant diversity and inclusiveness.
Thank you for your willingness to take part in the USDA/SNAP project to discuss job training/development programs. This project is separate from the state’s SNAP program and will not affect your benefits. Please answer the following questions to see if you qualify to take part in the virtual discussions.
Do you currently participate in a Supplemental Nutrition Assistance Program (SNAP) or a similar program (Foodshare/Food Stamp/Food Assistance/Nutrition Assistance)?
Yes
No [Thank and disqualify]
Not sure [Thank and disqualify]
Disqualify/End Survey Message: We’re sorry. Based on your answers, you don’t match the specific profile for the virtual discussions. This project is separate from the SNAP program in your state and will not affect your benefits. Thank you for your time and interest and in supporting the USDA/SNAP project. You may close your browser.
Do you currently take part in a job training/development program as part of food benefits support (SNAP/Foodshare/Food Stamp/Food Assistance/Nutrition Assistance)?
Yes [skip to Q4]
No
Not sure
Do you currently participate in the Temporary Aid for Needy Families (TANF) cash assistance program?
Yes [Thank and disqualify]
No
Not sure [Thank and disqualify]
What is your age?
18-24
25-34
35-44
45-54
55-59
60 or older [Thank and disqualify]
Please select all that apply related to your situation.
You are: (Select all that apply)
Working at least 30 hours a week
Taking care of a child under 6
Taking care of a person with disabilities
Unable to work due to a physical or mental limitation
Participating regularly in a substance (alcohol/drug) use disorder program
In school or a training program at least half-time
[If any above are selected, thank and disqualify]
What state do you currently live in? [Drop-down list of U.S. states] I do not live in the United States [Thank and disqualify]
What racial/ethnic group best describes you? (Select all that apply)
American Indian or Alaska Native
Asian/Pacific Islander
Black/African American
Hispanic/Latino/Latina
White, Caucasian
Other (specify)
Which most closely describes your gender identity?
Woman
Man
Transgender Woman
Transgender Man
Non-Binary
Agender/I don’t identify with any gender
Gender not listed. My gender is ______________
Prefer not to state
Thank you for answering these questions. You qualify to take part in the virtual discussions. Please advance to the next page to fill out your contact information and mark your choice for the time and date of the call.
Please select which group you can take part in below: [present one or more of the discussion options depending on whether the respondent participates in SNAP E&T/workforce development programs or not; state they are located in] (Select one)
Discussion 1 [Dates/Times TBD (individuals who are SNAP E&T/workforce development program participants)]
Discussion 2 [Dates/Times TBD (individuals who are not SNAP E&T/workforce development program participants)]
Discussion 3 [Dates/Times TBD [(individuals who are SNAP E&T/workforce development program participants)]
Discussion 4 [Dates/Times TBD (individuals who are not SNAP E&T/workforce development program participants)]
None of these days/times work for me [Skip to question 12]
Please complete the information below. Your information will be kept private and will not be shared with anyone outside our research team.
First Name:
Last Name:
Email address:
Mobile phone number (including area code):
You will receive a follow-up email to confirm the time and date of your discussion and information on how to connect to the call. We are looking forward to meeting you. Please note that you will receive a $75 electronic gift card after the call.
If you are unable to join at the day/time of the call, we thank you for your interest. This project is separate from the SNAP program in your state and will not affect your benefits. We will reach out to you if more calls are scheduled.
Thank you for your responses.
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This information is being collected to assist the Food and Nutrition Service in enhancing the effectiveness of current communications efforts. This is a voluntary collection and FNS will use the information to improve communication and marketing efforts to. This collection does request any 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 0584-0611. The time required to complete this information collection is estimated to average 0.083 hours 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 (0584-0611). Do not return the completed form to this address.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | SNAP OET |
| File Modified | 0000-00-00 |
| File Created | 2023-12-12 |