Form 1 Initial Interview

Generic Clearance for Census Bureau Field Tests and Evaluations

FoodAPS initial interview spec (English)_final

2025 National Household Food Acquisition Survey (FoodAPS) Pilot Test

OMB: 0607-0971

Document [docx]
Download: docx | pdf


Initial Interview/Household Survey

(To be completed by the primary householder.)

Intro

Welcome to the 2025 National Household Food Study.


Please enter the User ID and Password provided in the letter we sent you. If you need help or have questions, please visit census.gov/help/foodstudy, call 1-844-421-2603, or email [email protected]. Training videos and answers to frequently asked questions are available at census.gov/help/foodstudy.

HH enumeration

  1. The address we have on file appears below. Is this the address where you currently live?

{Fill street address

City, State, ZIP}

  1. Yes

  2. Yes, but I need to correct the address

3. No


[If 3(no)]

01a. You are not eligible to complete this survey. Thank you for your time.


[If 2 (yes but I need to correct the address)]

01aa.– Display editable address fields



[Hard edit if left blank]

A1a. What is your name?

[Two fields for First name and Last name]


[Hard edit if left blank]

A1b. What is your email?


A1_optout. We can also send updates, notifications, and survey links via text message. Would you like us to contact you by text message? Message and data rates may apply, depending on your mobile phone service plan. Message frequency varies. You can opt out of these messages at any time by replying STOP or reply HELP for more assistance. Our Terms of Service and Privacy Policy can be found here.

Link to this url:

English: https://census.gov/programs-surveys/foodstudy/information/sms-terms-conditions.html

Spanish: https://www.census.gov/programs-surveys/foodstudy/information_spanish/sms-terms-conditions-spanish.html



  1. Yes

  2. No


[if yes]

A1c. Please enter the cell phone number where you wish to receive text messages.


[If cellphone provided – use workflow in Qualtrics to pass this information on for text reminders.]

[Roster starts here]

A1e. Who lives at [fill address], even if they are not related to you? Please list all the people who will be living at your address over the next week. Include any babies or young children.

[Two fields for First name and Last name]


A1f. We do not want to miss anyone. The names listed so far are:

[List names that were provided in A1e]


Is there anyone else who USUALLY lives here, but is now away for reasons such as traveling for vacation or for work, in the military, or in the hospital?

(1) YES – Please list their names

(0) NO Go TO A1g


A1g. We do not want to miss anyone. The names listed so far are:

[List names that were provided in A1e and A1f]


Is there anyone else who lives here, such as a roommate, renter, or person you employ (for example, a babysitter)?


(1) YES – Please list their names

(0) NO


[Hard edit if left blank]

A2. Please select whether each person listed below will be here for the next [fill] days, away for the next [fill] days or is a guest that is visiting here temporarily.

Here for the next [fill] days: If the household member will be here [fill] days, please select ‘here for the next [fill] days.’

Away for the next [fill] days: If the household member will be away from home for the next [fill] days, please select ‘away for the next [fill] days

Visiting temporarily: By temporarily we mean anyone who is a guest staying in your home for less than 2 months.


[List all names selected in A1E, A1F and A1G with matrix style display with three response options: Here this week; Away this week; Guest visiting temporarily]


[Here this week – PR will get the proxy questions to determine who [proxy or self] will answer the income/profile questionnaire and food log]

[Away this week – PR proxies the profile/income questionnaire, no food log, included in HH count.]

[Visiting temporarily – they do not get the profile/income questionnaire or food log and are not included in household count; We will ask only demographics of the visiting temporarily, but we do not ask any of the other questions of the visitor.]

Food sharing section


[Ask A3D1_0 if more than 1 person in household]

A3D1_0. Do all people in your household share food?

Sharing food means purchasing and preparing meals together and eating household food.

Yes

No


[If yes do not ask food sharing questions as all people in household are in the PR food sharing group – All people in household that are here this week, get food log; skip to F1a/b]

[If no and more than 2 people in household – go to Fsg_pick group rank]


New Fsg_pick group rank. Select the names of the people listed below that share food with each other as a group. Sharing food means purchasing and preparing meals together and eating household food.

[Column headers:]

Food sharing group 1

Food sharing group 2

Food sharing group 3 (display if HH size>6)

Does not share food with anyone


[Ask F1a if A3D1_0= Yes OR hh_size = 1 OR (hh_size = 2 & A3d1_0 = No)]:

F1a. About how much of the food shopping do you do for your household?

  1. All of the food shopping

  2. More than half of the food shopping

  3. About half of the food shopping

  4. Less than half of the food shopping

  5. I rarely do the food shopping

  6. None, I don’t do any food shopping for my household


[Ask F1b if A3D1_0 = No and hh_size >2 ]:

F1b. About how much of the food shopping do you do for your food sharing group?

  1. All of the food shopping

  2. More than half of the food shopping

  3. About half of the food shopping

  4. Less than half of the food shopping

  5. I rarely do the food shopping

  6. None, I don’t do any food shopping for my food sharing group


[If F1a = 4/5/6]

F1aa. Please select the name of the person below who does half or more than half of the food shopping for your household.

[List household roster]

Someone outside of my household


[If F1b = 4/5/6]

F1bb. Please select the name of the person below who does half or more than half of the food shopping for your food sharing group.

[List household roster]

Someone outside of my household


[Ask F2a if A3D1_0= Yes]

F2a. About how much of the meal planning or meal preparation do you do for your household?

  1. All of the meal planning or preparation

  2. More than half of the meal planning or preparation

  3. About half of the meal planning or preparation

  4. Less than half of the meal planning or preparation

  5. I rarely do the food planning or preparation

  6. None, I don’t do any meal planning or preparation for my household


[Ask F2b if A3D1_0 = No and hh_size >2 ]:

F2b. About how much of the meal planning or meal preparation do you do for your food sharing group?

  1. All of the meal planning or preparation

  2. More than half of the meal planning or preparation

  3. About half of the meal planning or preparation

  4. Less than half of the meal planning or preparation

  5. I rarely do the meal planning or preparation

  6. None, I don’t do any meal planning or preparation for my food sharing group


(IF HHIZE=1 (SINGLE-PERSON HH, THEN ASSIGN THAT PERSON TO 1 AND THEN GO TO A6a


[List ALL NAMES FROM THE ROSTER – names that are in PR fsg will select shares food with me, names that are marked for fsg 1 are coded as being in that fsg; names that are check for fsg 2 are coded as being in that fsg, etc.]

Demographics and Education of PR

[Hard edit if left blank]

A6a What is your date of birth?


Month _____ Day____ Year _____


[Hard edit if left blank]

Please verify or enter correct age.

_____________YEARS


P1. Are you male or female?

  1. Male

  2. Female



P4. What is your race and/or ethnicity? Select all that apply.

  1. White

For example, English, German, Irish, , Italian, Polish, Scottish, etc.

  1. Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

  1. Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

  1. Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

  1. American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Tribal Government, Nome Eskimo Community, Aztec, Maya,, etc.

  1. Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

  1. Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.



IF AGE>=16, ASK P5. ELSE GO TO A11]

P5. What is the highest level of school you completed or the highest degree you received?

  1. Less than 1st grade

  2. 1st to 8th grade

  3. 9th to 12th grade, no diploma

  4. High school graduate with diploma or GED

  5. Trade/technical/vocational school

  6. One or more years of college, no degree

  7. Associate (2-year) college degree

  8. Bachelor’s degree (for example BA, AB, BS)

  9. Master’s or higher degree

________________________________________________________________________


[Loop through each person if A6 > =16; If PR answered 1 or 2 in A5 don’t show this question to the PR or to the person they said was 1 or 2]

A11. Are you currently married, widowed, divorced, separated, or never married?

(1) Married

(2) Widowed

(3) Divorced

(4) Separated

(5) Never married

(6) Other


[IF A11=1, GO TO A11b.]

A11b. Is your spouse a member of this household?


Display education questions starting at B5 for PR if they are age between 14 to 22. For the Primary Respondent remove any mention of kindergarten, elementary school; keep those in question stem and response options for other household members.


Note: P9C must be asked of EVERYONE over age 14. Not the age range of 5-22 as the other education questions are. This is because P9C is actually part of profile questionnaire.


[Display question if 14 or older]

P9C. Last week, were you enrolled in school as a full-time or part-time student, or were you not enrolled in school?


  1. Full-time student

  2. Part-time student

  3. Not enrolled in school


[Display education questions if respondent is between age 5 to 22]

B5. This week and next week are you attending classes for:

(1) Middle/junior high School

(2) High school

(3) Homeschool

(4) Other school (college, technical school, etc.)

(5) No, not attending classes


IF B5 = 5, GO TO B5a.


B5a. What is the reason you will not attend school this week and next week?

(1) Summer Vacation/Summer Break

(2) Other school break

(3) Home schooled

(4) Disabled

(6) Not enrolled

(7) Graduated

(8) Other


[IF B5A =1, GO TO B5A2]

B5A2. What is the level of school that you attended before summer break?

(1) Did not attend school

(2) Middle/junior high school

(2) High school

(3) Other school (college, technical school, etc.)


[If B5A=2 Go to B5A2a.]

B5A2a. What is the level of school that you attend when not on a school break?

  1. Middle/junior high school

  2. High school

  3. Other school (college, technical school, etc.)


[For people in household: Ask questions starting at B6 and going through to B9 questions only if person is in Kindergarten, elementary/grade school, middle/junior high school, high school]

[for PR ask only if they answer that they are in middle/junior and high school]


[IF B5A=1 or 2. GO TO B6a.]

B6a What are the first and last days of the school break or summer vacation?


FIRST DAY (MM/DD):_______________________

LAST DAY (MM/DD):_______________________

DON’T KNOW

[IF B5 IN (1, 2, 4) or B5a2 in (2,3,4,5), or B5A2a in (2,3,4,5) GO TO B5b. ELSE GO TO NEXT PERSON]

B5b. Is that school a public school, private school, or charter school?

(1) Public school

(2) Private school

(3) Charter school

(4) Other school type


[IF B5b IN (1,2, 3, 4), GO TO B5c. ELSE GO TO B6a1]

B5c. What is the name of that school?

We ask this question so that we can gather cafeteria menus from the schools.


_______________________


[Fill based on B5 or B5a if they are in school currently grades K-12 or on summer break grades k-12; for PR grades middle to highschool]

B6a1. [During the school year/Last school year], does your school serve school lunches? These are lunches that are free or that are paid for.

(1) YES

(0) NO SKIP TO B6D



[Fill based on answers to B5 or B5a if they are in k-12 school currently or on summer break]

B6b. [During the school year/Last school year], about how many days a week did you/ usually get a school lunch?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days


[IF B6B IN (1,2,3,4,5) ASK B6C. ELSE GO TO B6D]

[Fill tense based on B5/B5a if on school break or currently in school]

B6C. Did you get these lunches free, at a reduced price, at full price or are they included in tuition?

        1. Free

        2. Reduced-price

        3. Full Price

        4. Included in tuition


[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6D. [During the school year/Last school year], does your school serve school breakfasts? These are breakfasts that [are/were] free or that [are/were] paid for.

(1) YES

(0) NO SKIP TO B9


[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6E. [During the school year/Last school year], about how many days a week did you usually get a school breakfast?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days



[IF B6E IN (1,2,3,4,5), ASK B6F. ELSE GO TO B9.]

[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6F. Did you get these breakfasts free, at a reduced price, at full price or are they included in tuition?


        1. Free

        2. Reduced-price

        3. Full Price

        4. Included in tuition

[Loop ends.]


COMPLETE FOR CHILDREN WHO ARE IN SCHOOL (K-12) (b5=1,2,4,6 OR ON SCHOOL BREAK (B5a=1,2)


[Loop through each person]

[Fill based on answers to B5 or B5a if they are in school currently or on summer break – if summer break use last year/past tense]

B9. [During the school year/Last school year], where did you usually go right after school [is/was] over?

        1. My home

        2. Another home

        3. A park or recreation program

        4. A community or place of worship group

        5. Stays at school for an after-school program

        6. Stays at school for tutoring or a special class

        7. Some other place


[IF B9 IN (3, 4, 5, 6), GO TO B9a.]

[Fill based on answers to B5 or B5a if they are in school currently or on summer break – if summer break use last year/past tense]

IF B9 IN (3, 4, 5, 6) ASK B9a IMMEDIATELY AFTER, THEN GO TO NEXT NAME

B9a. Did you receive a snack from [this/that] program?

(1) YES

(0) NO


[IF B5a=1 (SUMMER BREAK) THEN GO TO B10_0.]


B10_0. Did you attend a summer program or summer camp?

  1. YES

  2. NO


[IF B10_0 = 1 (yes) ask:]

B10_01. How many days a week do you usually receive meals or snacks at the summer program or camp?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days


[If B10_01 is 2-8 then go to B10]

B10. Are these meals or snacks free, at a reduced price, at full price, or are they included in tuition?

        1. Free

        2. Reduced-price

        3. Full Price

        4. Included in tuition


[IF B5A=2 (OTHER SCHOOL BREAK, ASK B10B. ELSE MOVE TO NEXT PERSON OR GO TO INSTRUCTION BEFORE B11.]

B10B. Do you get free meals or snacks provided by the school system during school breaks?

  1. YES

  2. NO


Demographics and Education questions of HH members



[Loop through each person listed in A2.]

A5. Now you will be answering additional demographic questions about NAME.

What is NAME’s relationship to you?

(1) Spouse

(2) Unmarried Partner

(3) Child

(4)Step-child

(5) Grandchild

(6) Parent

(7) Brother/Sister

(8) Other Relative (for example, cousin, in-law)

(9) Foster Child

(10) Housemate/Roommate

(11) Renter/boarder/Person you employ

(12) Other non-relative


A6a. What is NAME’s date of birth?

If you do not know it, please provide as much information as you know. Then enter or confirm age in the age box. If you do not know the age, please provide an estimate in the age box.

For babies less than 1 year old, enter 0.


Month _____ Day____ Year _____


[Hard edit if left blank]

Verify or enter correct age.

____________________YEARS



P1. Is NAME male or female?

  1. Male

  2. Female


P4_h. What is NAME’s race and/or ethnicity? Select all that apply.

  1. White

For example, English, German, Irish, , Italian, Polish, Scottish, etc.

  1. Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

  1. Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

  1. Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

  1. American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Tribal Government, Nome Eskimo Community, Aztec, Maya,, etc.

  1. Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

  1. Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.


[display if any in 1-7 selected in P4_h]

P4_h_Intro. Next, we will collect detailed information for each race and/or ethnicity selected.


[display if 1 selected in P4_h]

P4_h_White. You said that NAME is White. Provide details below.
Select all that apply.

  1. English

  2. German

  3. Irish

  4. Italian

  5. Polish

  6. Scottish

  7. Enter, for example, French, Swedish, Norwegian, etc. __________________________________________________



[display if 2 selected in P4_h]

P4_h_Hispanic. You said that NAME is Hispanic or Latino. Provide details below.
Select all that apply.

  1. Mexican

  2. Puerto Rican

  3. Salvadoran

  4. Cuban

  5. Dominican

  6. Guatemalan

  7. Enter, for example, Colombian, Honduran, Spaniard, etc. __________________________________________________



[display if 3 selected in P4_h]

P4_h_Black_AA. You said that NAME is Black or African American. Provide details below.
 Select all that apply.

  1. African American

  2. Jamaican

  3. Haitian

  4. Nigerian

  5. Ethiopian

  6. Somali

  7. Enter, for example, Trinidadian and Tobagonian, Ghanian, Congolese, etc. __________________________________________________



[display if 4 selected in P4_h]

P4_h_Asian. You said that NAME is Asian. Provide details below.
Select all that apply.

  1. Chinese

  2. Asian Indian

  3. Filipino

  4. Vietnamese

  5. Korean

  6. Japanese

  7. Enter, for example, Pakistani, Hmong, Afghan, etc. __________________________________________________


[display if 5 selected in P4_h]

P4_h_AIAN.

You said that NAME is American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

________________________________________________________________



[display if 6 selected in P4_h]

P4_h_MENA. You said that NAME is Middle Eastern or North African. Provide details below.
Select all that apply.

  1. Lebanese

  2. Iranian

  3. Egyptian

  4. Syrian

  5. Iraqi

  6. Israeli

  7. Enter, for example, Moroccan, Yemeni, Kurdish, etc. __________________________________________________



[display if 7 selected in P4_h]

P4_h_NHPI. You said that NAME is Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

  1. Native Hawaiian

  2. Samoan

  3. Chamorro

  4. Tongan

  5. Fijian

  6. Marshallese

  7. Enter, for example, Chuukese, Palauan, Tahitian, etc. __________________________________________________


IF AGE>=16, ASK P5. ELSE GO TO A11]

P5. What is the highest level of school NAME completed or the highest degree NAME received?

  1. Less than 1st grade

  2. 1st to 8th grade

  3. 9th to 12th grade, no diploma

  4. High school graduate with diploma or GED

  5. Trade/technical/vocational school

  6. One or more years of college, no degree

  7. Associate (2-year) college degree

  8. Bachelor’s degree (for example BA, AB, BS)

  9. Master’s or higher degree

________________________________________________________________________


[Loop through each person if A6 > =16. If PR answered 1 or 2 in A5 don’t show this question to the PR or to the person they said was 1 or 2]

A11. Is NAME currently married, widowed, divorced, separated, or never married?

(1) Married

(2) Widowed

(3) Divorced

(4) Separated

(5) Never married

(6) Other


[IF A11=1, GO TO A11b.]

A11b. Is NAME’s spouse a member of this household?


Household education questions

Display education questions starting at 5B for all household members that are 14 to 22.

Note: P9C must be asked of EVEYONE over age 14. Not the age range of 5-22 as the other education questions are. This is because P9C is actually part of profile questionnaire.

[Display question if 14 or older]

P9C. Last week, was NAME enrolled in school as a full-time or part-time student, or was NAME not enrolled in school?


  1. Full-time student

  2. Part-time student

  3. Not enrolled in school


Loop through each person if AGE 5-22 (A6 <=22 and A6>=5)


B5. This week and next week is NAME attending classes for:

(1) Kindergarten

(2) Elementary/grade school

(4) Middle/junior high school

(6) High school

(7) Homeschool

(7) Other school (college, technical school, etc.)

(8) No, not attending classes


[IF B5 =0, GO TO B5a.]


B5a. What is the reason NAME will not attend school this week and next week?

(1) Summer vacation/summer break

(2) Other school break

(3) Home schooled

(4) Disabled

(5) Not old enough

(6) Not enrolled

(7) Graduated

(8) Other


[IF B5A =1, GO TO B5A2]

B5A2. What is the level of school that NAME attended before summer break?

(0) Did not attend school

(1) Primary or preschool

(2) Kindergarten

(3) Elementary/grade school

(4) Middle/junior high school

(5) High school

(6) Other school (college, technical school, etc.)


[If B5A=2 Go to B5A2a.]

B5A2a. What is the level of school that NAME attend/s when not on a school break?


(1) Primary or preschool

(2) Kindergarten

(3) Elementary/grade school

(4) Middle/junior high school

(5) High school

(6) Other school (college, technical school, etc.)


[For people in household Ask questions starting at B6 and going down through to B9 questions only if person is in Kindergarten, Elementary/grade school, Middle/junior high school, High school]

[IF B5A=1 or 2 . GO TO B6a.]

B6a What are the first and last days of the school break or summer vacation?


FIRST DAY (MM/DD):_______________________

LAST DAY (MM/DD):_______________________

DON’T KNOW

[IF B5 IN (1, 2, 4, 6) or B5a2 in (2,3,4,5), or B5A2a in (2,3,4,5) GO TO B5b. ELSE GO TO NEXT PERSON]

B5b. Is that school a public school, private school, or charter school?

(1) Public school

(2) Private school

(3) Charter school

(4) Other school type


[IF B5b IN (1,2, 3, 4), GO TO B5c. ELSE GO TO B6a1]

B5c. What is the name of that school?

We ask this question because we may gather cafeteria menus from the schools.


_______________________


[Fill based on B5 or B5a if they are in school currently grades K-12 or on summer break grades k-12; for PR grades middle to highschool]

B6a1. [During the school year/Last school year], does NAME’s school serve school lunches? These are lunches that are free or that are paid for.

(1) Yes

(0) No SKIP TO B6D



[Fill based on answers to B5 or B5a if they are in k-12 school currently or on summer break]

B6b. [During the school year/Last school year], about how many days a week does NAME usually get a school lunch?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days


[IF B6B IN (1,2,3,4,5) ASK B6C. ELSE GO TO B6D]

[Fill tense based on B5/B5a if on school break or currently in school]

B6C. Does NAME get these lunches free, at a reduced price, at full price or are they included in tuition?

(1) Free

(2) Reduced-price

(3) Full price

(4) Included in tuition


[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6D. [During the school year/Last school year], did /NAME’s school serve school breakfasts? These are breakfasts that [are/were] free or that [are/were] paid for.

(1) Yes

(0) No SKIP TO B9


[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6E. [During the school year/Last school year], about how many days a week [does/did] NAME usually get a school breakfast?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days



[IF B6E IN (1,2,3,4,5), ASK B6F. ELSE GO TO B9.]

[Fill based on answers to B5 or B5a if they are in school currently or on summer break]

B6F. [Does/Did] NAME get these breakfasts free, at a reduced price, at full price or are they included in tuition?


(1) Free

(2) Reduced-price

(3) Full price

(4) Included in tuition


COMPLETE FOR CHILDREN WHO ARE IN SCHOOL (K-12) (b5=1,2,4,6 OR ON SCHOOL BREAK (B5a=1,2)


[Fill based on answers to B5 or B5a if they are in school currently or on summer break – if summer break use last year/past tense]

B9. [During the school year/Last school year], where [does/did] NAME usually go right after school [is/was] over?

        1. My home

        2. Another home

        3. A park or recreation program

        4. A community or place of worship group

        5. Stays at school for an after-school program

        6. Stays at school for tutoring or a special class

        7. Some other place


[IF B9 IN (3, 4, 5, 6), GO TO B9a.]

[Fill based on answers to B5 or B5a if they are in school currently or on summer break – if summer break use last year/past tense]

IF B9 IN (3, 4, 5, 6) ASK B9a IMMEDIATELY AFTER, THEN GO TO NEXT NAME

B9a. [Does/did] NAME receive a snack from [this/that] program?

(1) YES

(0) NO


[IF B5a=1 (SUMMER BREAK) THEN GO TO B10_0.]


B10_0. [Do/Does] NAME attend a summer program or summer camp?

(1) YES

(0) NO


[IF B10_0 = 1 (yes) ask:]

B10_01. How many days a week [do/does /Name] usually receive meals or snacks at the summer program or camp?

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days

  7. 6 days

  8. 7 days


[If B10_01 is 2-8 then go to B10]

B10. Are these meals or snacks free, at a reduced price, at full price, or are they included in tuition?

(1) Free

(2) Reduced-price

(3) Full price

(4) Included in tuition


[IF B5A=2 (OTHER SCHOOL BREAK And K-12, ASK B10B. ELSE MOVE TO NEXT PERSON OR GO TO INSTRUCTION BEFORE B11.]

B10B. Does NAME get free meals or snacks provided by the school system during school breaks?

  1. YES

  2. NO


[Loop through each person if AGE (A6) ≤ 5 FOR B11 TO B11B.]


B11. Does NAME attend a child care center, in home day care, Head Start, Early Head Start, or preschool?

        1. Child care center

        2. In home day care

        3. Head Start

        4. Early Head Start

(5) Preschool

(6) Other, please specify ______________

(0) NO


[IF B11=1,2,3,4 ASK B11a & B11b IMMEDIATELY, BEFORE GOING TO NEXT NAME]


B11a. How many meals does NAME usually receive from their child care provider per week? Please provide your best estimate.


__________ meals


B11b. How many snacks does NAME usually receive from their child care provider per week? Please provide your best estimate.


__________snacks

[Loop ends.]


[IF AGE (A6) ≤ 2: loop through each person]

B13. Is NAME currently breastfed or fed breastmilk with a bottle?

(1) Yes

(0) No

SNAP

[Hard edit if left blank]

B1_0. Now we're going to ask you some questions about nutrition program participation.


Have you received benefits from the Supplemental Nutrition Assistance Program in the past 30 days? This program is also known as [FILL IN STATE SNAP NAME] or food stamps and it puts money on an EBT card that you can use to buy food.

(1) YES

(0) NO


[If no ask B1 and if more than 1 adult in household; over age of 18]

B1. Has anyone at this address received benefits from the Supplemental Nutrition Assistance Program in the past 30 days? This program is also known as [FILL IN STATE SNAP NAME] or food stamps and it puts money on an EBT card that you can use to buy food.

(1) YES

(0) NO ->SKIP TO B3


[If only 1 adult in household, or if 1 adult in household with children under age 18 skip B1B]

B1B. How many [FILL IN STATE SNAP NAME] EBT cards are issued to people at this address ?

(1) 1

(2) 2

(3) 3 or more


[If B1B= 1, then ask]

B1Ba. You said there is one [FILL IN STATE SNAP NAME] card in this household. Now we will ask about who in the household is assigned to the EBT card. Select the names of the people below that receive [FILL SNAP] benefits together under that EBT card.


Matrix List household roster


[If B1B= 2 then ask]

B1Bb. You said there are two [FILL IN STATE SNAP NAME] cards in this household. Now we will ask about who in the household is assigned to the two EBT cards. Select the names of the people below that receive [FILL SNAP] benefits together under those two EBT cards.

Matrix List household roster

{ FILL IN STATE SNAP NAME} Card 1

{ FILL IN STATE SNAP NAME } Card 2

Does not receive benefits


[If B1B= 3 then ask]

B1Bc. You said there are three or more [FILL IN STATE SNAP NAME] cards in this household. Now we will ask about who in the household is assigned to the first three EBT cards. Select the names of the people below that receive [FILL SNAP] benefits together under the first three EBT cards.

Matrix List household roster

{ FILL IN STATE SNAP NAME} Card 1

{ FILL IN STATE SNAP NAME } Card 2

{ FILL IN STATE SNAP NAME } Card 3

Does not receive benefits


[DisplayB1F if Yes to B1_0]

B1F. On what date did [you/you and names of SNAP group 1 from B1ba ] last receive [FILL IN STATE SNAP NAME] benefits?

MONTH: _______________________

DAY: ________________________

[Edit message on B1F – if more than 31 days ask edit:

You said that you received benefits in the past 30 days, but the date that you last received benefits is more than 30 days ago. Please confirm the date is correct.


[If they still report that the date is more than 31 days ago, go to B2 (it’s a soft edit)]


[Display B2 if Yes to B1_0]

B2. How many dollars were put on your EBT card the last time you received [FILL IN STATE SNAP NAME] benefits?

$: ________________________


[Display B2B if Yes to B1_0]

B2B. Is that the amount usually added each month, more than the usual amount, or less than the usual amount?

        1. The usual amount

        2. More than the usual amount

        3. Less than the usual amount



[IF B1=No]

B3. [Have you/Has anyone at this address] ever received benefits from SNAP?

(1) YES

(0) NO

(2) Don’t know


[IF B3=1, GO TO B3a. IF B3=0, or (2) don’t know, GO TO B12.]

B3a. Did (you/anyone at this address) receive benefits from SNAP in the last 12 months?

(1) YES

(0) NO


[IF B3a=1, GO TO B3b. IF B3a=0, GO TO B14. Display only if more than one in household]

B3b. Select the names of the people below that received benefits from SNAP during the last 12 months.

List roster


B3F. On what date did [you/someone at this address] last receive benefits from SNAP?

MONTH: _______________________

DAY: ________________________

YEAR: ________________________


B3G. How many dollars were put on the SNAP EBT card at that time?

$: ________________________

(97) DON'T KNOW


WIC

[IF ANY FEMALES BETWEEN 14 AND <53 OR CHILDREN < AGE 5, OTHERWISE GO TO C1.]

[Hard edit if left blank]

B14_h – The next few questions are about the Special Supplemental Nutrition Program for Women, Infants, and Children. WIC provides healthy foods and other services to low-income pregnant, breastfeeding or postpartum (non-breast feeding) women, infants, and children up to age 5.

Are you/Is anyone in your household now receiving benefits from WIC?

(1) YES

(2) NO


[IF B14_h=1 (yes), GO TO B14a. IF B14_h=2 (no), GO TO B12/C1.]

B14a. Select the names of the people listed below that currently receive WIC benefits, including infants and children.

SHOW list of FEMALE HOUSEHOLD MEMBERS BETWEEN 14 AND 54 AND CHILDREN <AGE 5 [select all display]



B14c. What month and year did (you/NAMES FROM B14a, B14b1, or if only one child <5 list that child’s name) start to receive benefits from the WIC program?

If there are different start dates, please report the earliest date.

Month_____

Year­­­­­_______


D3_1. There is a program called Medicaid that pays for health care for persons in need. Are you/Is anyone in your household covered by Medicaid?

(1) YES

(2) NO

If yes – display:

Select the names of the people below that are covered by Medicaid.

List names of people in household including PR


Pregnancy

SKIP QUESTIONS B12 – B14c IF HOUSEHOLD HAS NO FEMALES BETWEEN 14 AND <53 AND NO CHILDREN < AGE 6. In other words: SHOW the next statement IF HOUSEHOLD HAS FEMALES BETWEEN 14 AND <53 OR CHILDREN < AGE 6.


[IF ANY FEMALES BETWEEN 14 AND <53 ASK B12/B12a_2, ELSE GO TO B13.]


[For Single person household: and female between ages 14 and <53 display]

B12. Are you/Is anyone in your household currently pregnant

(1) YES

(0) NO


[IF B12 =1 GO TO B12a]

B12aa. Please select the names of the people who are pregnant from the list below.

List FEMALE HOUSEHOLD MEMBERS BETWEEN ages 14 AND <53

Where do you get food?


[Display if F1a=1,2 or 3 OR F2a=1,2 or 3]

Now we're going to ask you some questions about where you get food and drinks.


C.A. What day(s) of the week do you do most of your food shopping?

[Checkbox question]


Select all that apply.

  1. Monday

  2. Tuesday

  3. Wednesday

  4. Thursday

  5. Friday

  6. Saturday

  7. Sunday

  8. I do not have a day I typically food shop

C2. On average, how often do you do your main food shopping trip?

  1. More than once a week

  2. Once a week

  3. Once every 2 weeks

  4. Once every month

  5. I don’t do my main food shopping trip on a regular basis

[note to programmers: if PR answers 4, 5 or 6 for question F1 use “your household” wording, otherwise use “you”]

[Hard edit if left blank]

C1. Where do you/does your household do most of your food shopping?


Help video – How do I search for the food?


Please type the name and location below to search for the place. If you only enter the store name and the city, dozens of results may show. However, if you enter the store name, street address, city, and ZIP code, you will see fewer and more accurate locations.


__________________________

[STORE NAME, ADDRESS IS SAVED IN C1.]


C1b. What are your/your household’s main reasons for shopping at [store name]?

Select all that apply

  1. LOW PRICES

  2. CLOSE TO HOME

  3. CLOSE TO WORK

  4. VARIETY OF GOODS (GENERAL)

  5. GOOD QUALITY FOOD

  6. PRODUCE SELECTION

  7. MEAT DEPARTMENT

  8. VARIETY OF SPECIALTY FOODS (SUCH AS GLUTEN FREE, ORGANIC, CULTURAL FOODS)

  9. LOYALTY/FREQUENT SHOPPING PROGRAM

(10) ONLINE ORDERING

(11) I WORK/FAMILY MEMBER WORKS THERE

  1. OTHER



C1b1. How often do you/does your household shop at [store name] in a typical month?

(1) Daily

(2) Multiple times per week, but not daily

(3) Weekly

(4) Every other week

(5) About once a month

(6) Less often than once a month


C3_New_pre. Is there anywhere else where you typically shop for groceries aside from {store named in C1} in a typical month?

    1. Yes

    2. No


[Display C3 if ‘Yes’ in C3_New_pre]

C3. Besides (store name in C1), where else do you/does your household shop for groceries in a typical month?



____________________________

STORE NAME AND ADDRESS SAVED IN C3.


C3b. What’s the main reason you/your household shop at [store name]?

Select all that apply

  1. LOW PRICES

  2. CLOSE TO HOME

  3. CLOSE TO WORK

  4. VARIETY OF GOODS (GENERAL)

  5. GOOD QUALITY FOOD

  6. PRODUCE SELECTION

  7. MEAT DEPARTMENT

  8. VARIETY OF SPECIALTY FOODS (SUCH AS GLUTEN FREE, ORGANIC, CULTURAL FOODS)

  9. LOYALTY/FREQUENT SHOPPING PROGRAM

(10) ONLINE ORDERING

(11) I WORK/FAMILY MEMBER WORKS THERE

  1. OTHER


[Display this question if B1_0=1(yes)]

C3bb. Do you use most of your benefits from [FILL IN STATE SNAP NAME] at [Fill store from C1 or at Fill store from C3]?

  1. Yes, from [fill C1]

  2. Yes, from [fill C3]

  3. No


[Display this question if B1_0=1(yes) AND if 2-No to C3bb ask C3bbb]

C3bbb. Where do you do most of your food shopping when using your benefits from [FILL IN STATE SNAP NAME]?


____________________________

STORE NAME



[IF B14=2 (no) THEN GO TO C4. If B14=1(yes) ask C3wic]

C3wic. Do you/does your household use most of your WIC benefits at [fill from c1, c3, or c3bbb]

  1. Yes, from [fill C1]

  2. Yes, from [fill C3]

  3. Yes, from [fill C3bbb]

  4. No


[If no ask:]

C3C. Where do you go to shop for most of your WIC items?

____________________________

STORE NAME


C4. In a typical month, do you ever grocery shop anywhere else even for just a few items?

(1) YES

(0) NO


[IF C4 =1, GO TO C4a.]

C4a. In a typical month, how many different places do you shop for groceries?

NUMBER: _____


[If if C4 = 1]

C5. During the past 30 days, did you spend money on groceries at any of the following locations? Select all that apply


  1. SUPERMARKET OR GROCERY STORE

  2. DISCOUNT OR BIG BOX STORE LIKE TARGET OR WALMART

  3. WHOLESALE CLUB LIKE B.J.’S, COSTCO, OR SAM’S CLUB

  4. CONVENIENCE STORE

  5. DOLLAR STORE

  6. PHARMACY OR DRUG STORE

  7. SPECIALTY STORES SUCH AS MEAT OR FISH MARKETS, BAKERIES

  8. ONLINE RETAILER OR STORE, like amazon.com

  9. OTHER, please specify: ______________________


C9d. Thinking about all the places you get/your household gets groceries, in a typical week, about how much do you/does your household spend on groceries? Your best guess is fine.

$_______ WEEKLY


C9e. How often do you shop with a grocery list?

(1) Never

(2) Rarely

(3) Sometimes

(4) Most of the time

(5) Almost always


[do not display this question if on question F1a or F1b -=6 (never do food shopping)]

C10. The following questions are about [FILL IN PRIMARY STORE NAME FROM C1], the store where you buy most of your groceries. How do you usually get to [FILL IN PRIMARY STORE NAME FROM C1]?

(1) DRIVE OWN CAR
(2) USE SOMEONE ELSE’S CAR

(3) SOMEONE ELSE DRIVES ME

(4) WALK

(5) BUS, SUBWAY, OR PUBLIC TRANSPORTATION
(6) TAXI OR RIDESHARE, LIKE UBER OR LYFT

(7) RIDE BICYCLE
(8) STORE DELIVERS GROCERIES TO MY HOME

(9) Other, please specify: __________________

[IF C10 IN (1, 2, 3), GO TO C11.

C11. How long does it take to go one way from home to [FILL IN PRIMARY STORE NAME FROM C1]?

________________________ minutes


IF C10 IN (5, 6), GO TO C10a.

C10a. How much do you usually pay out of pocket for a single one-way trip to [FILL IN PRIMARY STORE NAME FROM C1]

$____.__

Display C10b if C10 in [4, 5, 6, 7, 8]

C10b. Do you or someone in your household have access to a car when you need one?

(1) YES

(0) NO


IF C10=8, GO TO C10c.

C10c. On average, for one order, how much do you pay for the delivery?

$_______


[FEEDING AMERICA Universe: asked of all PRs]

C7a. When in season, do you have a fruit or vegetable garden?

(1) YES

(0) NO


C7b. Do you receive free fruits or vegetables from anyone else’s garden, orchard, or trees?

(1) YES

(0) NO


C7d. Do you get food by hunting or fishing?

(1) YES

(0) NO


C7c. When in season, do you ever get food from a Farmer’s Market, farm stand, or Community Supported Agriculture (CSA)?

(1) YES

(0) NO


C6. Sometimes people need help getting food for their household. There are many programs in the community that can help.


During the past 30 days, have you or anyone in your household gotten free groceries from a food pantry, food bank, place of worship, or other place that helps with free food?


(1) YES

(0) NO


C6a. During the past 30 days, have you or anyone in your household received a free meal from a place of worship, shelter, home-delivered meal service like Meals on Wheels, or other place that helps with free meals?

(1) YES

(0) NO

Primary Householder Profile Questions

[Universe: PR]

Now you will answer questions about your personal food and health habits.


P16. How many times do you get breakfast away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P17. How many times do you get lunch away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P18. How many times do you get dinner away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P7a. In general, would you say your health is …

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor


[IF AGE>=14, ASK P7B. ELSE GO TO P7C]

P7b. Do you smoke cigarettes, cigars, E-cigarettes, pipes, or chew tobacco?

  1. Yes

  2. No


P7c. [IF P1=1 female or blank AND AGE>=14, SHOW:] Other than during pregnancy, have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?

[OTHERWISE, SHOW:] Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=14, ASK P7D. ELSE GO TO SKIP INSTRUCTION BEFORE P7E]

P7d. Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=14, ASK P7E. ELSE GO TO SKIP INSTRUCTION BEFORE P8]

P7e. Have you ever been told by a doctor or other health professional that your blood cholesterol level was high?

  1. Yes

  2. No

  3. Don’t know


P6_UNITS: The next questions are about your height and weight.

In what units will you report your height?

  1. Feet and Inches GO TO P6

  2. Meters and Centimeters GO TO P6


P6. How tall are you? Please provide your best estimate.


___Feet ___inches

___Meters __centimeters

Don’t know my height GO TO P7_UNITS


P7_UNITS: In what units will you report your weight?

  1. Pounds (LBS) GO TO P7

  2. Kilograms (KG) GO TO P7


P7. How much do you weigh? Please provide your best estimate.

___pounds

___kilograms

  1. Don’t know my weight GO TO P7_CAT1


[IF P6_UNITS=3 (DON’T KNOW) AND P7_UNITS=1 OR 2, THEN CALCULATE BMI AS P7 DIVIDED BY SQUARE OF P6 IF REPORTED IN STANDARD METRICS OR P7 DIVIDED BY SQUARE OF P6 AND TIMES 703 IF REPORTED IN POUNDS AND INCHES.


IF AGE>17 AND (BMI<18 OR BMI>54),

SHOW soft edit:

Verifyhw_“Please verify your height and weight.”

[allow respondent to modify height and weight but they can ignore message and move forward without correcting]


[IF AGE>18 AND P7_UNITS=3 (DON’T KNOW) AND P6_UNITS=1 OR 2, ASK P7_CAT1 AND P7_CAT2. ELSE GO TO P19.]


[PROGRAMMER NOTE: FILL IN XX BASED ON HEIGHT REPORTED IN P6. XX IS THE BMI CUTOFF BETWEEN OVERWEIGHT AND OBESITY (according to .3 33%)]

P7_CAT1. Do you weigh more or less than [XX]?

  1. More SKIP TO P19

  2. Less GO TO P7_CAT2

  3. Same SKIP TO P19

  4. Don’t know GO TO P7_CAT2


[PROGRAMMER NOTE: FILL IN YY BASED ON HEIGHT REPORTED IN P6. YY IS THE BMI CUTOFF BETWEEN NORMAL WEIGHT AND OVERWEIGHT (According to .25 25%).]

P7_CAT2. Do you weigh more or less than [YY]?

  1. More

  2. Less

  3. Same

  4. Don’t know


[IF AGE>=17 THEN ASK P8. ELSE GO TO G1]

P8. Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

    1. Yes

    2. No


[P8a. If yes to P8,]

P8a. Were you on active duty ONLY FOR TRAINING in the Reserves or National Guard?

  1. Yes

  2. No


[If no/ missing to P8a]

P8b. Are you currently on active duty?

  1. Yes

  2. No

Tenure (Rent/Own)

[This series of questions is for the PR only – if single person household use ‘you’ as fill; if multiple people use ‘your household’ for fills]


G1. Do you/Does your household rent or own your home?

  1. Rent

  2. Own

  3. Other, do not pay for housing


[IF G1=1 (RENT) ASK G4. OTHERWISE GO TO G2]

G4. Is your rent/your household’s rent covered fully or in part by the Federal, State, or Local government?

  1. Yes

  2. No


[IF G1=3 (OTHER, DO NOT PAY), ASK G3. OTHERWISE GO TO G4]

G3. Is your rent/your household’s rent covered fully by a local public housing authority or other public agency?

  1. Yes

  2. No


G2. Do you/Does anyone in your household own or lease a vehicle, like a car or truck?

  1. Yes

  2. No


[IF G2=1 (YES), ASK G5]

G5. How many vehicles do you/does your household own or lease?

____________ vehicles



[IF G1=1 (RENT) OR 2 (OWN), ASK G6B. ELSE GO TO G9]

G6B. How frequently do you/does your household pay the [G1=2: mortgage/G1=1: rent]?

Options for Rent

Options for Mortgage


Every other week

Weekly

Monthly

Every other week

Quarterly

Twice per month

Semiannually

Monthly

Annually

Other

Do not pay mortgage SKIP TO G7A0


G6A. How much do you/does your household usually pay for [G1=2: the mortgage/G1=1: rent] [insert fill from G6B]? If you don’t usually pay anything, enter 0 below.

$______


[IF G6A=0, GO TO SKIP INSTRUCTION BEFORE G7A0.

IF G6A>0 AND G1=2 (OWN), ASK G6A1.

ELSE GO TO SKIP INSTRUCTION BEFORE G7A0]

G6A1. Which of the following are included in this payment? Select all that apply.

  1. Principal

  2. Interest

  3. Property tax

  4. Homeowner’s insurance

  5. Other expenses


[IF “HOMEOWNERS INSURANCE” IS CHECKED IN G6A1, GO TO SKIP INSTRUCTIONS BEFORE G8A0. ELSE ASK G7A0]

G7A0. Do you/Does your household pay [G1=2: homeowners/G1=1: renters] insurance?

  1. Yes, paid separately from rent/mortgage GO TO G7B

  2. Yes, paid as part of rent/mortgage GO TO SKIP INSTRUCTIONS BEFORE G8A0

  3. No, I do not pay insurance / No, does not pay insurance GO TO SKIP INSTRUCTIONS BEFORE G8A0

G7B. How frequently do you/does your household pay for [G1=2: homeowners/G1=1: renters] insurance?

  1. Monthly

  2. Quarterly

  3. Semiannually

  4. Annually


G7A. How much do you/does your household usually pay for [G1=2: homeowners/G1=1: renters] insurance [fill answer from G7B]?

If you don't know the exact amount, providing your best estimate is acceptable.

$______


[IF “PROPERTY TAX” IS CHECKED IN G6A1 OR G1=1 (RENT) OR 3 (NO HOUSING PAY), GO TO G9. ELSE ASK G8A0- so basically only those that own and did not already check property tax get this question]

G8A0. Do you/does your household pay real estate or property tax on your home?

  1. Yes, paid separately from mortgage GO TO G8B

  2. Yes, paid as part of mortgage GO TO G9

  3. No, does not pay real estate or property taxes GO TO G9


G8B. How frequently do you/does your household pay for real estate or property tax on your home?

  1. Monthly

  2. Quarterly (every 3 months)

  3. Semiannually (every 6 months)

  4. Annually


G8A. How much do you/does your household usually pay for real estate or property tax on your home [insert fill from G8B]?

$______


G9. Over the past month, have you/has your household had any unusually large and unexpected expenses?

  1. Yes

  2. No

PR Work Questions

The following questions ask about work-related activities last week. By last week, we mean the week beginning on Sunday, [FILL IN: DATE], and ending on Saturday, [FILL IN: DATE].


P9D. Last week, did you do any work for either pay or profit?

  1. Yes

  2. No

[if P9D=2 and age is >40]

P9a. Did you retire before last week?

  1. Yes GO TO P9A1

  2. No GO TO P9B

P9a1. Did you retire early because of a disability?

  1. Yes

  2. No

  3. Rather not answer

Universe: P9D – yes or P9a - no

P9B. Do you own a business or a farm?

  1. Yes

  2. No

[IF P9D=1 (YES), GO TO P9E.

ELSE IF P9D =2 (NO), AND P9A=1 (yes), GO TO P9E.

ELSE ASK P9D1]

P9D1. What is the main reason you did not work last week?

  1. Taking care of house/family

  2. Disabled

  3. On layoff (temporary or indefinitely)

  4. Slack work/business conditions

  5. Waiting for new job to begin

  6. Vacation/personal days

  7. Own illness/injury/medical problems

  8. Child care problems

  9. Maternity/paternity leave

  10. Other family/personal obligation

  11. Labor dispute

  12. Weather affected job

  13. School/training

  14. Civic/military duty

  15. Retired

  16. Other, please specify: __________________


P9E. Are you currently looking for a job, either full or part time?

  1. Yes

  2. No


[IF P9A = 1 (YES) AND P9D = 2 (NO) GO TO I1.

ELSE ASK P10]

P10. Did you work for pay or profit for more than one employer last week?

  1. Yes, more than one employer GO TO P11

  2. No, only one employer GO TO P11


P11. How many hours do you normally work for pay, including paid sick time and paid leave time?

__________ Hours per week


[IF P11 = 0, GO TO I1.]

P12.

[IF P10=2 (NO),] What shift or shifts do you work? Select all that apply.

[IF P10=1 (YES), SHOW:] What shift or shifts do you work across all jobs? Select all that apply.

  1. Day shift (for example morning to early evening)

  2. Swing shift (for example early evening to midnight)

  3. Night shift (for example midnight to morning)

  4. Varying schedule (not a fixed schedule)


If P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely)

P14a. [IF P10=1 YES ask ‘across all jobs,’ otherwise if P10 = 2, no one job, leave that phrase off): [Across all jobs,] Do you commute to work at least once a week?

  1. Yes, commute to work at least once a week GO TO P14

  2. No, work from home or telework every dayGO TO I1_Annual.


If P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely)

P14 .

[IF P10=2 (NO),:]

How long does it usually take you to get from home to work?


[IF P10=1 (YES), SHOW:]

For your primary job, how long does it usually take you to get from home to work?

________ Hours

________ Minutes


Universe: P9D – yes OR (P9a = no AND P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely); does not = 4 (Slack work/business conditions); does not = 5 (Waiting for new job to begin); does not = 13 (School/training))

P15. When at work, where do you usually get food (for example, for lunch or dinner)?

  1. Workplace, for purchase

  2. Workplace, for free

  3. Purchase from store/restaurant/food truck

  4. Bring food from home

  5. Do not eat food at work

PR Income Questions

The next set of questions asks about your income. This information helps USDA understand how much money people have available to spend on food.


I1_Annual. What was your household’s total income before taxes last year in [FILL IN PREVIOUS YEAR]?


$__________


[SHOW IF I1_Annual is skipped]

I1_Annual_b. Please select the range that best reflects your household’s total income before taxes last year in [FILL IN PREVIOUS YEAR]?


  1. Less than $5,000

  2. $5,000 to $7,499

  3. $7,500 to $9,999

  4. $10,000 to $12,499

  5. $12,500 to $14,999

  6. $15,000 to $19,999

  7. $20,000 to $24,999

  8. $25,000 to $29,999

  9. $30,000 to $34,999

  10. $35,000 to $39,999

  11. $40,000 to $49,999

  12. $50,000 to $59,999

  13. $60,000 to $74,999

  14. $75,000 to $99,999

  15. $100,000 to $149,999

  16. $150,000 or more


I1. Did you receive any wages, salary, commissions, bonuses, or tips last month?

Do not include self-employment income.

  1. Yes

  2. No [skip to I2]

[SHOW I1_last_paycheck if I1=Yes]

I1_last_paycheck. On what date did you receive your last paycheck?

If you do not know the exact day, please use your best guess.__/__/__ mm/dd/yyyy



I1a. What is the easiest way for you to tell us about your earnings from work before taxes and other deductions?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Yearly

  6. Lump-sum or one-time payment


I1b. How much did you receive [Response from I1a] in wages, salary, commissions, bonuses, or tips from all jobs before taxes and other deductions?

$_______________.00


I1c. According to our calculations, you received [calculate TOTAL FROM I1b and I1a by month] altogether in earnings from work last month before taxes and other deductions. Is that correct?

  1. Yes

  2. No


[IF I1c=0 (NO), ASK I1d. ELSE GO TO NEXT question].

I1d. What is your best estimate of the correct total amount that you received in income from earnings from work before taxes and other deductions last month?

$ __________


I2. Did you receive any self-employment income last month? Report income from own businesses (farm or non-farm) including proprietorships and partnerships.

  1. Yes

  2. No

[IF yes ask I2a; if no skip to I3]

I2a.What is the easiest way for you to tell us about your earnings from self-employment income?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Yearly

  6. Lump-sum or one-time payment


I2b. How much did you receive [Response from I2a] in self-employment income before taxes and other deductions?

$_______________.00


[Display this only if weekly, every other week, or twice a month, and yearly. Do not do it for Monthly]

I2c. According to our calculations, you received [calculate TOTAL FROM I2a and I2b by month] altogether in earnings from self-employment income last month before taxes and other deductions. Is that correct?

  1. Yes

  2. No


[IF I2c=0 (NO), ASK I2d. ELSE GO TO NEXT question].

I2d. What is your best estimate of the correct total amount that you received in self-employment income before taxes and other deductions last month?

$ __________.00


I3. Did you receive any Social Security or Railroad Retirement benefits last month?

  1. Yes

  2. No

[IF yes]

I3b. What was the amount?

$_______________.00


I4. Did you receive any Supplemental Security Income (SSI) payments last month?

  1. Yes

  2. No

[IF yes]

I4b. What was the amount?

$_______________.00


I5. Did you receive any Temporary Assistance for Needy Families (TANF) benefits last month?

  1. Yes

  2. No

[IF yes]

I5b. What was the amount?

$_______________.00


I6. Did you receive any other cash assistance from state or local welfare programs last month?

  1. Yes

  2. No

[IF yes]

I6b. What was the amount?

$_______________.00


I7. Did you receive any survivor or disability income last month?

  1. Yes

  2. No

[IF yes]

I7b. What was the amount?

$_______________.00


I9. Did you receive any payments from the Department of Veterans Affairs (VA) last month?

Do not include salary payments if employed by the VA.


  1. Yes

  2. No

[IF yes]

I9b. What was the amount?

$_______________.00


I8. Did you receive a pension or any retirement income from a previous employer or union, or any regular withdrawals or distributions from retirement accounts such as 401(k), 403(b), IRA, Roth IRA, or other accounts designed specifically for retirement last month?

Do not include disability compensation from the VA.

  1. Yes

  2. No

[IF yes]

I8b. What was the amount?

Do not include Social Security.

$_______________.00



I10. Did you receive any income from any other sources such as unemployment compensation, child support,alimony, or investments last month?

  1. Yes

  2. No

[IF yes]

I10b. What was the amount from all other sources?

$_______________.00


[If no income reported above:]

I11. We do not want to miss any income sources. Please consider earnings from work, unemployment compensation, welfare, child support, alimony, retirement, disability, investment, and any other sources of income. Did you receive income last month?

  1. Yes, I received income last month GO TO I1, cycle through the questions one more time then got o I13.

  2. No, I did not receive income last month GO TO I13A.


I13. How much does your household have in cash, checking accounts, saving accounts, money markets, or other assets that are easily converted to cash?

  1. Zero

  2. $1 to $2,750

  3. $2,751 to $,4250

  4. $4,251 or more


Proxy Questions for profile/income food log


Proxy intro: To understand how people in the United States get their food we need additional detailed information about work, school, health, income and food for each person at your address. It is recommended that everyone 14 years and over answer these questions for themselves. However, if for any reason someone can’t or won’t report for themselves, we will ask you to report for them.


[Hard edit if left blank] Proxy1: Are the following people able and willing to answer additional questions about health, school, work and income for themselves, or will you answer for them?

  • By selecting "will report for themselves" for anyone 17 or younger, you are giving permission for them to receive the survey.

  • Everyone that reports for themselves will need to have their own email address. We can not reuse email addresses.


[Matrix of list of names with “Will report for themselves” “I will report for them” as response option] 


[Hard edit if left blank] Proxy2: Are the following people able and willing to complete daily surveys about what food they get each day over the next week, or will you answer for them?

  • By selecting "will report for themselves" for anyone 17 or younger, you are giving permission for them to receive the survey.

  • Everyone that reports for themselves will need to have their own email address. We can not reuse email addresses.


[Matrix of list of names with “Will report for themselves” “I will report for them” as response option] 


Contact info for household members that will get their own questionnaire

[Go through all household roster names age ≥14 that PR said would answer the income/profile questionnaire OR the food log on their own and ask for the email/cell phone number so we can send them their own questionnaire. Only capture this info if the PR said that NAME will report for themselves; only ask one time.]


A3B_CI2. In order for the members of your household to receive the survey and participate for themselves, we need to collect their contact information.

Everyone that will receive the survey to participate and report for themselves will need to have their own email address.


Does NAME have their own email address?

Yes

No, NAME does not have their own email address, so I will report for them.


[if no, skip to end of block – e.g., next person in household that PR said would report for themselves; if yes, display A3B_CI2_yes]


A3B_CI2_yes. What is NAME’s email address?

[open text field]


A3B_opt in. We can also send updates, notifications, and survey links via text message. Would [Name] like us to contact them by text message?

Message and data rates may apply, depending on [Name]’s mobile phone service plan. Message frequency varies. [Name] can opt out of these messages at any time by replying STOP or reply HELP for more assistance. Our terms of Service and Privacy Policy can be found here.

English: https://census.gov/programs-surveys/foodstudy/information/sms-terms-conditions.html

Spanish: https://www.census.gov/programs-surveys/foodstudy/information_spanish/sms-terms-conditions-spanish.html


Yes

No


[if yes]

A3B2. Please enter the cell phone number where NAME wishes to receive text messages.

PROXY Household Profile questionnaire and Income sections

[HH Proxy profile questions for P2-P12. PR will answer for those aged <14, and anyone else the PR indicates will be proxied]


P16. Now you will be answering additional questions about NAME.

As a reminder, you will earn an additional $5 if you answer these questions about NAME.

How many times does NAME eat breakfast away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P17. How many times does NAME eat lunch away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P18. How many times does NAME eat dinner away from home during an average week? This includes restaurants, school and workplace cafeterias, fast-food, take-out, and delivery. Please provide your best estimate.

________ times


P7a. In general, would you say NAME’s health is …

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor


[IF AGE>=14, ASK P7B. ELSE GO TO P7C]

P7b. Does NAME smoke cigarettes, cigars, E-cigarettes, or pipes, or chew tobacco?

  1. Yes

  2. No


P7c. [IF P1=1 female AND AGE>=14, SHOW:] Other than during pregnancy, has NAME ever been told by a doctor or other health professional that NAME has diabetes or sugar diabetes?

[OTHERWISE, SHOW:] Has NAME ever been told by a doctor or other health professional that they have diabetes or sugar diabetes?

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=14, ASK P7D. ELSE GO TO SKIP INSTRUCTION BEFORE P7E]

P7d. Has NAM} ever been told by a doctor or other health professional that NAME had hypertension, also called high blood pressure?

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=14, ASK P7E. ELSE GO TO SKIP INSTRUCTION BEFORE P8]

P7e. Has NAME ever been told by a doctor or other health professional that NAME’s blood cholesterol level was high?

  1. Yes

  2. No

  3. Don’t know


P6_UNITS: The next questions are about NAME’s height and weight.

In what units will you report NAME’s height?

  1. Feet and Inches GO TO P6

  2. Meters and Centimeters GO TO P6


P6. [IF AGE>=2, SHOW:] How tall is NAME? Please provide your best estimate.

[IF AGE < 2, SHOW:] How tall is NAME when lying down and measured from head to toe? Please provide your best estimate.


___Feet ___inches

___Meters __centimeters

Don’t know NAME’s height GO TO P7_UNITS



P7_UNITS: In what units will you report { /NAME’s} weight?

  1. Pounds (LBS) GO TO P7

  2. Kilograms (KG) GO TO P7


P7. How much { /does NAME} weigh? Please provide your best estimate.

___pounds

___kilograms

Don’t know NAME’s weight GO TO P7_CAT1


[IF P6_UNITS=3 (DON’T KNOW) AND P7_UNITS=1 OR 2, THEN CALCULATE BMI AS P7 DIVIDED BY SQUARE OF P6 IF REPORTED IN STANDARD METRICS OR P7 DIVIDED BY SQUARE OF P6 AND TIMES 703 IF REPORTED IN POUNDS AND INCHES.


IF AGE>17 AND (BMI<18 OR BMI>54),

SHOW soft edit:

Verifyhw_“Please verify NAME’s height and weight.”

[allow respondent to modify height and weight but they can ignore message and move forward without correcting]


[IF AGE>18 AND P7_UNITS=3 (DON’T KNOW) AND P6_UNITS=1 OR 2, ASK P7_CAT1 AND P7_CAT2. ELSE GO TO P19.]


[PROGRAMMER NOTE: FILL IN XX BASED ON HEIGHT REPORTED IN P6. XX IS THE BMI CUTOFF BETWEEN OVERWEIGHT AND OBESITY (according to .3 33%)]

P7_CAT1. Does NAME weigh more or less than [XX]?

  1. More SKIP TO P19

  2. Less GO TO P7_CAT2

  3. Same SKIP TO P19

  4. Don’t know GO TO P7_CAT2


[PROGRAMMER NOTE: FILL IN YY BASED ON HEIGHT REPORTED IN P6. YY IS THE BMI CUTOFF BETWEEN NORMAL WEIGHT AND OVERWEIGHT (According to .25 25%).]

P7_CAT2. Does NAME weigh more or less than [YY]?

  1. More

  2. Less

  3. Same

  4. Don’t know


[IF AGE>=17 THEN ASK P8. ELSE GO TO G1]

P8. Has NAME ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

  1. Yes

  2. No


[P8a. If yes to P8,]

P8a. Was Name on active duty ONLY FOR TRAINING in the Reserves or National Guard?

  1. Yes

  2. No


[If no/ missing to P8a]

P8b. Is Name currently on active duty?

  1. Yes

  2. No

[Household Proxy work questions for PR to Proxy for P2-P12 for those of age ≥14 and that PR indicated they would proxy report for; also for those that were marked ‘away this week’]


The following questions ask about work-related activities last week. By last week, we mean the week beginning on Sunday, [FILL IN: DATE], and ending on Saturday, [FILL IN: DATE].


[Need age restriction for this series –>14]

[loop through all people that PR is answering for ]


P9D. Last week, did NAME do any work for either pay or profit?

  1. Yes

  2. No

[if P9D=2 and age is >40]

P9a. Did NAME retire before last week?

  1. Yes GO TO P9A1

  2. No GO TO P9B

P9A1. Did NAME retire early because of a disability?

  1. Yes

  2. No

  3. Rather not answer

P9B. Did NAME own a business or a farm?

  1. Yes

  2. No

[IF P9D=1 (YES), GO TO P9E.

ELSE IF P9D =2 (NO), AND P9A=1 (RETIRED), GO TO P9E.

ELSE ASK P9D1]

P9D1. What is the main reason NAME did not work last week?

  1. Taking care of house/family

  2. Disabled

  3. On layoff (temporary or indefinitely)

  4. Slack work/business conditions

  5. Waiting for new job to begin

  6. Vacation/personal days

  7. Own illness/injury/medical problems

  8. Child care problems

  9. Maternity/paternity leave

  10. Other family/personal obligation

  11. Labor dispute

  12. Weather affected job

  13. School/training

  14. Civic/military duty

  15. Retired

  16. Other, please specify: __________________


P9E. Is NAME currently looking for a job, either full or part time?

  1. Yes

  2. No


[IF P9A = 1 (YES) AND P9D = 2 (NO) GO TO P16.

ELSE ASK P10]

P10. Did NAME work for pay or profit for more than one employer last week?

  1. Yes, more than one employer GO TO P11

  2. No, only one employer GO TO P11


P11. On average about how many hours does NAME normally work (and get paid) per week, including paid sick time and paid leave time?

__________ Hours per week


[IF P11 = 0, GO TO A3.]

P12.

[IF P10=2 (NO),] What shift or shifts does NAME work? Please check all that apply.

[IF P10=1 (YES), SHOW:] What shift or shifts does NAME work across all jobs? Select all that apply.

  1. Day shift (for example morning to early evening)

  2. Swing shift (for example early evening to midnight)

  3. Night shift (for example midnight to morning)

  4. Varying schedule (not a fixed schedule)


If P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely)

P14a. [IF P10=1 YES ask ‘across all jobs,’ otherwise if P10 = 2, no one job, leave that phrase off): [Across all jobs,] Does NAME commute to work at least once a week?

  1. Yes, commute to work at least once a week GO TO P14

  2. No, work from home or telework every dayGO TO


If P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely) and yes on P14a

P14 .

[IF P10=2 (NO),:]

How long does it usually take NAME to get from home to work?

[IF P10=1 (YES), SHOW:]

For your primary job, how long does it usually take NAME to get from home to work?

________ Hours

________ Minutes


If P9D1 does not = 15 (Retired); does not =1 (Taking care of house/family; does not =2(Disabled); does not = 3 (On layoff (temporary or indefinitely)

P15. When at work, where does NAME usually get food (for example, for lunch or dinner)?

  1. Workplace, for purchase

  2. Workplace, for free

  3. Purchase from store/restaurant/food truck

  4. Bring food from home

  5. Do not eat food at work



[Household Proxy Income series for the PR to proxy of age ≥14; income questions are for those over age ≥14]


The next set of questions asks about income that members in your household received last month. This information helps USDA understand how much money people have available to spend on food.



I1. Did NAME receive any wages, salary, commissions, bonuses, or tips last month?

Do not include self-employment income.

  1. Yes

  2. No [SKIP TO I2]

[SHOW I1_last_paycheck if I1=Yes]

I1_last_paycheck. On what date did NAME receive their last paycheck?

__/__/__ mm/dd/yyyy


[IF yes, If no, skip to I2]

I1a. What is the easiest way for you to tell us about NAME’s earnings from work before taxes and other deductions?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Yearly

  6. Lump-sum or one-time payment


I1b. How much did NAME receive [Response from I1a] in wages, salary, commissions, bonuses, or tips from all jobs before taxes and other deductions?

$_______________.00


I1c. According to our calculations, NAME received [calculate TOTAL FROM I1b and I1a by month] altogether in earnings from work last month before taxes and other deductions. Is that correct?

  1. Yes

  2. No


[IF I1c=0 (NO), ASK I1d. ELSE GO TO NEXT question].

I1d. What is your best estimate of the correct total amount that NAME received in income from earnings from work before taxes and other deductions last month?

$ __________


I2. Did NAME receive any self-employment income last month? Report income from own businesses (farm or non-farm) including proprietorships and partnerships.

  1. Yes

  2. No

[IF yes ask I2a; if no skip to I3]

I2a.What is the easiest way for you to tell us about NAME’s earnings from self-employment income?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Yearly

  6. Lump-sum or one-time payment


I2b. How much did NAME receive [Response from I2a] in self-employment income before taxes and other deductions?

$_______________.00


[Display this only if weekly, every other week, or twice a month, and yearly. Do not do it for Monthly]

I2c. According to our calculations, NAME}received [calculate TOTAL FROM I2a and I2b by month] altogether in earnings from self-employment income last month before taxes and other deductions. Is that correct?

  1. Yes

  2. No


[IF I2c=0 (NO), ASK I2d. ELSE GO TO NEXT question].

I2d. What is your best estimate of the correct total amount that NAME received in self-employment income before taxes and other deductions last month?

$ __________.00


I3. Did NAME receive any Social Security or Railroad Retirement benefits last month?

  1. Yes

  2. No

[IF yes]

I3b. What was the amount?

$_______________.00


I4. Did NAME receive any Supplemental Security Income (SSI) payments last month?

  1. Yes

  2. No

[IF yes]

I4b. What was the amount?

$_______________.00


I5. Did NAME receive any Temporary Assistance for Needy Families (TANF) benefits last month?

  1. Yes

  2. No

[IF yes]

I5b. What was the amount?

$_______________.00


I6. Did NAME receive any other cash assistance from state or local welfare programs last month?

  1. Yes

  2. No

[IF yes]

I6b. What was the amount?

$_______________.00


I7. Did NAME receive any survivor or disability income last month?

  1. Yes

  2. No

[IF yes]

I7b. What was the amount?

$_______________.00


I9. Did NAME receive any payments from the Department of Veterans Affairs (VA) last month?

Do not include salary payments if employed by the VA.


  1. Yes

  2. No

[IF yes]

I9b. What was the amount?

$_______________.00


I8. Did NAME receive a pension or any retirement income from a previous employer or union, or any regular withdrawals or distributions from retirement accounts such as 401(k), 403(b), IRA, Roth IRA, or other accounts designed specifically for retirement last month?

Do not include disability compensation from the VA.


  1. Yes

  2. No

[IF yes]

I8b. What was the amount?

Do not include Social Security.

$_______________.00



I10. Did NAME receive any income from any other sources such as unemployment compensation, child support,alimony, or investments last month?

  1. Yes

  2. No

[IF yes]

I10b. What was the amount from all other sources?

$_______________.00


[If no income reported above:]

I11. We do not want to miss any income sources. Please consider earnings from work, unemployment compensation, welfare, child support, alimony, retirement, disability, investment, and any other sources of income. Did NAME receive income last month?

  1. Yes, NAME received income last month GO TO I1 (Cycle back through ONE time, on second time GO to I14)

  2. No, NAME did not receive income last month GO TO I14.


Submit

Once you click Submit below, you will earn a $[FILL] gift card for completing this part of the study, which can be redeemed after your study period closes.


After you click the Submit button below, these are the next steps for you:

  1. You will receive an email with information on how to complete the next part of the study, where we ask you to report the food and drinks you [and proxy names] get over the next [FILL] days. You will earn a $[FILL] gift card for completing all [FILL] days of food and drink reporting.

  2. Then, we will ask you to complete the final part of the study, where we gather information about your experience completing the study, for which you will earn a $15 gift card.


Submit_AP

[If count_nonproxied is >/= 1]

If additional people live in your household and you said they will complete the rest of the study on their own, these are the next steps for them:

        1. They will receive an email with information on how to complete the next part(s) of the study, which include food and drink reporting and/or questions on health, work, and income. Household members will earn a $[FILL] gift card for completing all [FILL] days of food and drink reporting and a $5 gift card for completing questions on health, work, and income.



Submit Button


End of Survey Message

We thank you for the time spent taking this survey. 

Please check your email for information on the study's next steps.


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