Form 1 Income and Profile Questionnaire

Appendix Q: Combined profile and income questionnaire

(To be completed by all household members other than the PR. PR proxy reports for age <11.)

P0. Thank you for your participation in this important food study. You will earn a $X incentive upon completion of this questionnaire.

Questions from profile-starts with health

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

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

[IF AGE>=16, ASK P7B. ELSE GO TO P7C]

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

1. Yes

2. No

P7c. [IF P1=2 AND AGE>=16, 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

[IF AGE>=16, 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

[IF AGE>=16, 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

P6_UNITS: More Qs about health

The next questions are about your height and weight.

Do you report your height in feet and inches or in meters and centimeters?

1. Feet and Inches GO TO P6

2. Meters and Centimeters GO TO P6

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

___Feet ___Inches

___Meters __Centimeters

Don’t know my height GO TO P7_UNITS

P7_UNITS: Do you report your weight in pounds or kilograms?

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

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: “Please verify your height and weight.” AND BRING PEOPLE BACK TO P6 AND P7]

[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]

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.]

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

1. More

2. Less

3. Same

4. Don’t know

[Q’s about military]

[IF AGE>=17 THEN ASK P8. ELSE GO TO P16.]

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

Yes

No

[P8a. If yes to P8,]

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

Yes

No

[If no/ missing to P8a]

Are you currently on active duty?

Yes

No

[Food related questions]

P16. How many times do you 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 do you 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 do you 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

[CPS - work related questions; Asked of those doing self report age >14]

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]

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

P9B. Do you own a business or a farm?

1. Yes

2. No

P9C. Last week, were you enrolled in school as a full-time or part-time student?

1. Yes, full-time

2. Yes, part-time

3. 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 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. 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 P16.

ELSE ASK P10]

P10. Did you receive earnings or wages from more than one employer last week?

1. Yes, more than one employer GO TO P11

2. No, only one employer GO TO P11

3. Did not receive any earnings or wages last week SKIP TO P16

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

__________ Hours per week

[IF P11 = 0, GO TO P16]

P12.

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

[IF P10=1 (YES), SHOW:] What shift or shifts do you work across all jobs? Please check 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)

P13.

[IF P10=2 (NO),:]

On what date did you receive your last paycheck?

[IF P10=1 (YES), SHOW:] On what date did you receive your last paycheck from your primary job?

__/__/__ mm/dd/yyyy

P14a. [IF P10=1 (YES): 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 dayGO TO P16

P14 .

[IF P10=2 (NO), 4 (DON’T KNOW), 5 (RATHER NOT ANSWER), SHOW:]

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

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

[Income series starts here; ask income questions of those age >14; we are skipping retirement for those <55 – or whatever is the cut off on the updated age A6C question.]

The next set of questions asks about income that you received last month to help USDA understand how much money people have available to spend on food.

[Programmer note: If any of the yes/no income questions are left blank do a soft edit that says “Please answer this important question.”]

I1. Did you receive any wages, salary, commissions, bonuses, or tips during the past month?

1. Yes

2. No

[IF yes]

I1a. What is the easiest way for you to tell us how often you are paid?

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 during the last month. 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 in the last month?

$ __________

[Skip if respondent age is <14]

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

1. Yes

2. No

[IF yes]

I2a.What is the easiest way for you to tell us the how often you receive 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?

$_______________.00

I2c. According to our calculations, you received [calculate TOTAL FROM I2a and I2b by month] altogether in earnings from work during the last month. 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 in the last month?

$ __________.00

[Skip if respondent age is <14; Programmer note: display I3b and I3 on same page]

I3. Did you receive any Social Security or Railroad Retirement benefits during the past month?

1. Yes

2. No

[IF yes]

I3b. What was the amount?

$_______________.00

[Skip if respondent age is <14; Programmer note: display 14 and 14b on same page]

I4. Did you receive any Supplemental Security Income (SSI) payments during the past month?

1. Yes

2. No

[IF yes]

I4b. What was the amount?

$_______________.00

[Skip if respondent age is <14; Programmer note: Display 15 and I5b on same page]

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

1. Yes

2. No

[IF yes]

I5b. What was the amount?

$_______________.00

[Skip if respondent age is <14; Programmer note, display I6 and 6b on same page]

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

1. Yes

2. No

[IF yes]

I6b. What was the amount?

$_______________.00

[Skip if respondent age is <14; programmer note – display I7 and I7b on same page]

I7. Did you receive any survivor or disability income during the past month?

1. Yes

2. No

[IF yes]

I7b. What was the amount?

$_______________.00

[Skip if respondent age is <55; Programmer note: display I8 and I8b on same page]

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 during the past month?

1. Yes

2. No

[IF yes]

I8b. What was the amount?

Do not include Social Security.

$_______________.00

[Skip if respondent age is <14; Programmer note – Display I9 and I9b on same page]

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

Do not include salary payments if employed by the VA.

1. Yes

2. No

[IF yes]

I9b. What was the amount?

$_______________.00

[Skip if respondent age is <14; Programmer note – Display I10 and I10b on same page]

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

1. Yes

2. No

[IF yes]

I10b. What was the amount from all sources?

$_______________.00

If no income reported above:

[Skip if respondent age is <14]

I11. USDA would like you to report all sources of income including earnings from work, unemployment compensation, welfare, child support, alimony, retirement, disability, investment and any other sources of income. Are you sure that you did not receive any income in the last month?

1. Yes, I received income last month GO TO I1

2. No, I did not receive any income last month GO TO SKIP INSTRUCTIONS BEFORE I12A.

[IF RESPONDENT IS AGED 18 OR OLDER, SELF-REORTING, FLAGGED TO RECEIVING SNAP (B1B FROM INITIAL INTERVIEW IS CHECKED), and IS NOT IN PR’S SNAP UNIT (FROM INITIAL INTERVIEW), ASK I12A. ELSE GO TO SKIP to end.]

[PROGRAMMER: DISPLAY I12A, I12B, I12C, AND I12D ON ONE SCREEN]

I12a. On what date did you last receive benefits from SNAP? This program used to be called food stamps and, in your state, it is called [FILL IN STATE SNAP NAME]. It puts money on a SNAP EBT card that you can use to buy food.

MONTH: ________

DAY: ___________

YEAR: __________

I12b. How many dollars were put on your SNAP EBT card the last time you received SNAP benefits?

$_____________

I12c. 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

I12Dd. What is the number on your SNAP EBT card?

This number will only be used for purposes of matching to program administrative records. Your data will be used for statistical purposes only and will be kept strictly confidential.

SNAP EBT CARD NUMBER: ____________________________

• RATHER NOT ANSWER

END. Thank you very much for completing this questionnaire. You’ve earned a $X incentive for your household.

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