2 Initial Interview

Generic Clearance for Questionnaire Pretesting Research

Appendix R Initial Interview

Usability and Cognitive Evaluation for the Data Collection Instrument of FoodAPS-2 Pilot Study

OMB: 0607-0725

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Appendix R: Initial Household Interview

(To be completed by the primary householder.)

INITIAL INTERVIEW

SECTION A: 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]

01aa.– Display address fields again but editable


A1a. What is your name?


A1b. What is your email?


A1c. What is your phone number?


A1d. Is this number a cell phone or land line?

  1. Cell phone

  2. Land line

  3. Neither



If A1d = (1) Cell phone-- Display A1dd, otherwise skip to A1e.:


A1dd. We send survey invitations and reminders via text message. Are text message invitations and reminders acceptable on this number?

Yes

No


[If Yes – use workflow in Qualtrics to pass this information on for texting and emailing 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.

[PR lists names]


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


[Matrix of names provided in A1E, A1F and A1G]

A2. Please select whether each person listed below will be here this week, is currently away, or is a guest that is visiting here temporarily.

By temporarily we mean anyone who is visiting for less than 2 months.

If the person will be here part of the week, please select ‘here this week.’


[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]


[Name that is here this week—will get the income/profile questionnaire]

[Guest that is visiting temporarily -they do not get the income/profile questionnaire and are not included in household count)

[Go through all names that were marked as Away this week – and ask the following:]

A3. Does {name} contribute financially to this household’s expenses?

Yes

No

[If yes away this week– then PR will answer their income/profile questionnaire; they will not get the food log]

[If no and away this week - they will be included in the household count; then PR will answer their income/profile questionnaire; they will not get the food log – even if the respondent says that they are in the PRs food sharing group]

[Food sharing section]

F1. Do you do most of the shopping for food in your household?

If you shop for 50% or more of the food, answer Yes.

(1) YES

(0) NO


F2. Do you do most of the meal planning or meal preparation in your household?

If you plan or prepare meals 50% or more of the time, answer Yes.

(1) YES

(0) NO



(IF HHIZE=1 (SINGLE-PERSON HH, THEN ASSIGN THAT PERSON TO 1 AND THEN GO TO P1 (formerly A4))


[Ask A3D1 if more than 1 person in household]


A3D1_0. Sharing food means people who purchase and prepare meals together and people who eat the household food. Do all people in your household share food?

Yes

No


[If yes do not ask food sharing questions – A3D1, A3D2, A3Da, All people in household that are here this week, get food log]


[If no and more than 2 people in household – go to A3D1]



A3D1. Select the names of the people listed below that share food with you.

Sharing food means people who purchase and prepare meals together, and people who eat the household food.

[List ALL NAMES FROM THE NEW HOUSEHOLD ROSTER with last response option as No one shares food in the household; The names listed here are in the PR food sharing group. They will get the Food Log. But if they are listed here and are away this week – pull this info from roster matrix – then they will not answer the Food Log]


  1. Assign to each name listed here a 1 –

  2. If all names are selected skip to A5 and assign Food sharing group FSG=1 TO EVERYONE IN THE ROSTER

  3. If some names remain unchecked go to A3D2


A3D2. Of the names listed below, select the names of the people who share food together.

Sharing food means people who purchase and prepare meals together and people who eat the household food.

[LIST names that were not checked in A3D1 with last option as no one on this list shares food.]


A3D2a. Of the names listed below, select the names of the people who share food together.

Sharing food means people who purchase and prepare meals together and people who eat the household food.

[LIST names that were not checked in A3D2 with last option as no one on this list shares food. Continue to cycle through all list of household member names until we have understanding of people in household that share food]


[Demographics of HH members]



[Loop through each person listed in A2.]

A5. What is (NAME’s) relationship to you?

(1) Spouse

(2) Unmarried Partner

(3) Child/Step-child/Adopted child

(4) Grandchild

(5) Parent

(6) Brother/Sister

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

(8) Foster Child

(9) Housemate/Roommate

(10) Roomer/Boarder/Lodger/Employed Person

(11) Other non-relative



(formerly A4) P1. What sex {were you/was NAME} assigned at birth, on {your/NAME’s} original birth certificate?

  1. Female

  2. Male


(A4.1) P2. How [do you/does Name] currently describe[s] [yourself/themselves]? (Select all that apply)

  1. Female

  2. Male

  3. Transgender

  4. I use a different term, please specify: ________________________



(A4.2) P3. Just to confirm, [you were/Name was] assigned {FILL} at birth and now [you/Name] describe[s] [yourself/themselves] as {FILL}. Is that correct?

    1. Yes

    2. No – skip back to correct

A6. How old (are you/is NAME)?

For babies less than 1 year old, enter 0.


____________________YEARS


A6a What is (your/NAME’s) date of birth?

Month _____ Day____ Year _____

[IF A6 IS left blank FOR ANYONE, ASK A6C UNTIL WE GET AN AGE CATEGORY FOR ALL WHO PROVIDED MISSING DATA TO A6.]


A6C. What age range [Are you/ Is NAME]?

  1. Under 6 months,

  2. 6 months to under 1 year old,

  3. 1 to less than 2

  4. 2 to less than 5

  5. 5 to less than 11

  6. 11 to less than 14

  7. 14 to less than 16

  8. 16 to less than 18

  9. 18 to less than 22

  10. 22 to less than 55

  11. 55 to less than 60

  12. 60 or older


P4. What is {your/NAME’s} race or ethnicity? Select all that apply. Note, you may report more than one group.

  1. White

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

  1. Hispanic or Latino

For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

  1. Black or African American

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

  1. Asian

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

  1. American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

  1. Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, 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/NAME} completed or the highest degree {you/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. One or more years of college, no degree

  6. Associate (2-year) college degree

  7. Bachelor’s degree (e.g., BA, AB, BS)

  8. Master’s or higher degree

________________________________________________________________________




[Loop through each person if A6 > =16 OR A6C >= 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/ 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?


Section B: [Participate in nutrition programs?]


B1_0. Have you received benefits from [FILL IN STATE SNAP NAME] in the past 30 days? This program is also known as 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]

B1. Has anyone at this address received benefits from [FILL IN STATE SNAP NAME] in the past 30 days? This program is also known as 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 with children under age 21 skip B1B]

B1B. How many SNAP EBT cards are issued to people at this address ?

(1) 1

(2) 2

(3) 3 or more


B1Ba. Select the names of the people below that receive SNAP benefits from your EBT card.

List household roster {as a select all that apply}

With last response option: No one on this list


[If 1 skip to B1F] [If 2 or more ask:]

B1C. Select the names of the people below that receive SNAP benefits together under the same EBT card.

{List of names that were not checked in B1Ba}



[only ask this question if B1B = 3 or more]

B1Ca. Select the names of the people below that receive SNAP benefits together under the same EBT card.

{List of names that were not checked in B1C}


[DisplayB1F if Yes to B1_0]

B1F. On what date did [you/ insert names of snap group 1 from B1ba including PR’s name too] 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


[Display B2C if Yes to B1_0]

B2C 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 LOOP; GO TO P9C.]


[IF B1=No]

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

(1) YES

(0) NO

(2) Don’t know



[IF B3=1, GO TO B3a. IF B3=0, or (2) don’t know, GO TO P9C.]

B3a. Did (you/anyone at this address) receive benefits FROM [FILL IN STATE SNAP NAME] in the last 12 months?

(1) YES

(0) NO


[IF B3a=1, GO TO B3b. IF B3a=0, GO TO P9C. Display only if more than one in household]

B3b. Select the names of the people below that received benefits from [FILL IN STATE SNAP NAME] during the last 12 months.

List roster



If B3=(1) yes, or B3a = (1) yes, display B3F and B3G, otherwise go to P9C]

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

MONTH: _______________________

DAY: ________________________

YEAR: ________________________


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

$: ________________________

(97) DON'T KNOW



GO TO P9C

Education questions

[Loop through each person if AGE 5-22 ((A6 <=22 and A6>=5) OR A6C IN (5,6,7,8,9).

If P9C =3 (no) skip]

P9C. Last week, { was NAME} enrolled in school as a full-time or part-time student?


  1. Yes, full-time

  2. Yes, part-time

  3. No


B5. This week and next week [is NAME] attending classes for kindergarten, elementary or grade school, middle school or junior high school, high school, or some other school (college, technical school, etc.)?

(0) No

(1) Kindergarten

(2) Elementary/GRADE School

(4) Middle/junior high School

(6) High School

(7) Other School (College, Technical School, etc.)


[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) attends when not on a school 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 B5A2 or B5A2a. 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), 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 or on summer break]

B6a1. During [the school year/last school year], does [ NAME’s] school serve school lunches? These are complete 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 school currently or on summer break]

B6b. During the [school year/last school year], about how many days a week [did/does] [NAME] usually get a complete 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 Does NAME] get these lunches free, at a reduced price, or [do they] pay full price?

(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, [does/did] [NAME’s] school serve school breakfasts? These are complete breakfasts that are free or that are 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, about how many days a week [does/did] [NAME] usually get a complete 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, or [does/did] [they] pay full price?


(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 year], where [does/did] (NAME) usually go right after school is over?

(1) YOUR 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 program?

(1) YES

(0) NO


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


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

  1. YES

  2. NO


B10_01. How many days a week 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 1-5 then go to B10]

B10. Are these meals or snacks free, at a reduced price, or [does] Name] pay full price?

(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. [Does] (NAME) get free meals or snacks provided by the school system during school breaks?

  1. YES

  2. NO



[Loop ends]



[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, or Early Head Start?

(1) CHILD CARE CENTER

(2) IN HOME DAY CARE

(3) HEAD START

(4) EARLY HEAD START

(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? ENTER #

__________

B11b. How many snacks per week does (NAME) usually receive from (their) child care provider? ENTER #

__________

[Loop ends.]



SKIP QUESTIONS B12 – B14c IF HOUSEHOLD HAS NO FEMALES BETWEEN 14 AND 54 AND NO CHILDREN < AGE 6.


In other words: SHOW the next statement IF HOUSEHOLD HAS FEMALES BETWEEN 12 AND 50 OR CHILDREN < AGE 6.


[IF ANY FEMALES BETWEEN 14 AND 54 (A4=2 and 12=<A6<=50) or (A4=2 and A6c=2,3,4), ASK B12, ELSE GO TO B13.]

B12. Is anyone in your household currently pregnant?

(1) YES

(0) NO


[Look through each person]


[IF B12 =1 GO TO B12a]

B12a. Please select the names of the people who are pregnant from the list below.

List FEMALE HOUSEHOLD MEMBERS BETWEEN ages 14 AND 54


[IF AGE (A6) ≤ 2:]

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

(1) Yes

(0) No


[Loop ends.]


[IF ANY FEMALES BETWEEN 14 AND 54 OR CHILDREN < AGE 5, OTHERWISE GO TO C1.]


B14. The next few questions are about the WIC program - the Women, Infants, and Children program. 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.

Is anyone in your household now receiving benefits from WIC?

(1) YES

(0) NO


[IF B14=1, GO TO B14a. IF B14=0, GO TO B15.]

B14a. Select the names of the people listed below that currently receive WIC benefits.

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


[if household has children < age 5 and no children is checked at b14a. AND a female household member is checked ask B14b; THEN loop through all female members if there are multiple situations like this]

B14b. Is (NAME) receiving WIC for herself, for a child, or for both herself and a child?

(1) HerselfSKIP TO B14C

(2) A ChildGO TO SKIP INSTRUCTION BEFORE B14B1

(3) BothGO TO SKIP INSTRUCTION BEFORE B14B1

(97) Don’t Know SKIP TO B14C


[IF HH HAS MORE THAN ONE CHILD LESS THAN 5, ASK B14B1. IF HH HAS ONLY ONE CHILD LESS THAN 5, GO TO B14C]

B14B1. For which child or which children?

List HOUSEHOLD MEMBERS <=5 AS RESPONSE OPTIONS (select all display)


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

Month_____

Year­­­­­_______


[Loop ends.]

Section C: [Where do you get food?]


The next questions are about where you get food.


C1. Where do you do most of your food shopping?


__________________________

[STORE NAME, ADDRESS IS SAVED IN C1.]


C1a What kind of store is that?

(1) Supermarket

(2) Small grocery store

(3) Convenience store

(4) Discount or big box store like Target or Walmart

(5) Wholesale club like B.J.’s, Costco, or Sam’s Club

(6) Other


C1b. What are your main reasons for shopping at this store?

CHECK 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/CONVENIENCE

(11) I WORK/FAMILY MEMBER WORKS THERE

  1. OTHER



C1b1. How often do you shop at that store in a typical month? Would you say….

(1) Daily

(2) Multiple times per week, but not daily

(3) Weekly

(4) Every other week

(5) About once a month, or

(6) Less often than once a month





C3.

Besides {store named in C1}, where else do you do most of your food shopping?”



____________________________

STORE NAME AND ADDRESS SAVED IN C3.



C3a What kind of store is that?

(1) Supermarket

(2) Small grocery store

(3) Convenience store

(4) Discount or big box store like Target or Walmart

(5) Wholesale club like B.J.’s, Costco, or Sam’s Club

(6) Other


C3b. What’s the main reason you shop at this store or place? CHECK 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/CONVENIENCE

(11) I WORK/FAMILY MEMBER WORKS THERE

  1. OTHER


New SNAP household sequence

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 C1

  2. Yes from C3

  3. No


[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

C3bbba What kind of store is that?

(1) Supermarket

(2) Small grocery store

(3) Convenience store

(4) Discount or big box store like Target or Walmart

(5) Wholesale club like B.J.’s, Costco, or Sam’s Club

(6) Other



[IF B14^=0 THEN GO TO C4.]

C3wic

Does your household] use most of your WIC benefits from [fill from c1, c3, or c3bbb]

Yes C1

Yes C3

Yes C3bbb

No


[If no ask:]

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

PROGRAMMER: SHOW A LIST OF LOCAL WIC-AUTHORIZED STORES AS A DROP-DOWN MENU.

STORE NAME: ____________________

STORE ADDRESS: _________________




C4. (Do you ever 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: _____ (Range 1-25)


[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. DISCOUNT OR BIG BOX STORE LIKE TARGET OR WALMART

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

  3. CONVENIENCE STORE

  4. DOLLAR STORE

  5. PHARMACY OR DRUG STORE

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

  7. ONLINE RETAILER OR STORE, like amazon.com

  8. OTHER, please specify: ______________________

  9. NO, NO STORES OTHER THAN SUPERMARKETS OR GROCERY STORES





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?

(1) YES

(0) NO


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

$_______ WEEKLY




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

(1) Never

(2) Seldom

(3) Sometimes

(4) Most of the time

(5) Almost always


[Transportation to store]


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. IF C10 IN (5, 6), GO TO C10a. IF C10 IN (4,7, 8) GO TO C10b.]


C10a. How much do you usually pay out of pocket for a single one-way trip to this store?

$____.__

GO TO C11



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. ELSE GO TO C11.]

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

$_______


C11. How long does it take to go one way from home to this store?

________________________ minutes



GO TO C6 - Feeding America

[FEEDING AMERICA]

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



To understand what factors influence whether or not American’s have enough food to eat, we need detailed information…

detailed information about work, school, health, income and food for each person at your address. It is recommended that everyone over the age of 10 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.


Are the following people able and willing to complete the questions about health, school, work and income for themselves, or will you report this information for them?

List names of everyone in household


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 report this information for them?

List names of those in food sharing group]


[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]

[List all household roster names age >11 and ask for their email/cell phone number so we can send them their own questionnaire.]

A3B. What is [Name’s] email address?

A3B2. What is [Name’s] cell phone number?

A3B3. Would [Name] prefer to be contacted by email or text?


Profile questions added here that PR will answer about self and those aged <11?]


P16. How many times [do you/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 [do you/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 [do you/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 {your health/NAME’s 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/Does NAME} smoke cigarettes, cigars, E-cigarettes, or pipes, or chew tobacco?

  1. Yes

  2. No


P7c. [IF P1=1 AND AGE>=16, SHOW:] Other than during pregnancy, {have you/has NAME} ever been told by a doctor or other health professional that {you have/NAME has} diabetes or sugar diabetes?

[OTHERWISE, SHOW:] {Have you/Has NAME} ever been told by a doctor or other health professional that {you have/NAME has} diabetes or sugar diabetes?

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=16, ASK P7D. ELSE GO TO SKIP INSTRUCTION BEFORE P7E]

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

  1. Yes

  2. No

  3. Don’t know


[IF AGE>=16, ASK P7E. ELSE GO TO SKIP INSTRUCTION BEFORE P8]

P7e. {Have you/Has NAME} ever been told by a doctor or other health professional that {your/NAME’s} blood cholesterol level was high?

  1. Yes

  2. No

  3. Don’t know


P6_UNITS: The next questions are about {your/NAME’s} height and weight.

In what units will you report {your/NAME’s} height?

  1. Feet and Inches GO TO P6

  2. Meters and Centimeters GO TO P6


P6. [IF AGE>=2, SHOW:] How tall {are you/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 {my/NAME’s} height GO TO P7_UNITS



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

  1. Pounds (LBS) GO TO P7

  2. Kilograms (KG) GO TO P7


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

___pounds

___kilograms

  1. Don’t know {my/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: “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]

P7_CAT1. {Do you/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.]

P7_CAT2. {Do you/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. {Have you/Has NAME} ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

Yes

No


[P8a. If yes to P8,]

[Was Name /Were you] on active duty ONLY FOR TRAINING in the Reserves or National Guard?

Yes

No


[If no/ missing to P8a]

[Are you /Is Name] currently on active duty?

Yes

No



[This series of questions is for the PR only – if single person household need to use ‘you’ as fill if PR has indicated in their food sharing group that there are multiple people we will 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] covered fully or in part by the Federal, State, or Local government? If your rent is covered by military housing, select No.

  1. Yes

  2. No


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

G3. Is [your 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 does your household pay for [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: 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 GO TO G7B

  2. Yes, paid as part of other expenses GO TO SKIP INSTRUCTIONS BEFORE G8A0

  3. 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 “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 GO TO G8B

  2. Yes, paid as part of other expenses GO TO G9

  3. No, does not pay 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 month)

  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 that affected your spending on food this week?

  1. Yes

  2. No


[From Profile Questionnaire – Work questions come from the CPS]


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 – is it age >15]

[loop through all people that PR is answering for ]


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

  1. Yes

  2. No

[if P9D=2 and age is >54]

P9a. Did {you/NAME} retire before last week?

  1. Yes GO TO P9A1

  2. No GO TO P9B

P9A1. Did {you/NAME} retire early because of a disability?

  1. Yes

  2. No

  3. Rather not answer

P9B. {Do you/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 {you/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. {Are you/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 {you/NAME} 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/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 P16]

P12.

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

[IF P10=1 (YES), SHOW:] What shift or shifts {do you/does NAME} 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/NAME} receive {your/their} last paycheck?

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

__/__/__ mm/dd/yyyy


P14a. [IF P10=1 (YES): Across all jobs, {do you/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 P16


P14 .

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

How long does it usually take {you/NAME} to get from home to work?


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

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

________ Hours

________ Minutes


P15. When at work, where {do you/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

[Income series for the PR and PR proxy of age >XX]

The next set of questions asks about income that {you / members in your household} 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 on the screen that says “Please answer this important question.”]


I1. Did you/NAME 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 /NAME is } 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/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, {you/NAME} 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/NAME} received in income from earnings from work before taxes in the last month?

$ __________


I2. Did you/NAME 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 how often {you receive/NAME receives} 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/NAME] receive [Response from I2a] in self-employment income before taxes?

$_______________.00

I2c. According to our calculations, {you/NAME} 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/NAME} received in self-employment income before taxes in the last month?

$ __________.00


I3. Did [You/NAME] receive any Social Security or Railroad Retirement benefits during the past month?

  1. Yes

  2. No

[IF yes]

I3b. What was the amount?

$_______________.00


I4. Did [You/NAME] receive any Supplemental Security Income (SSI) payments during the past month?

  1. Yes

  2. No

[IF yes]

I4b. What was the amount?

$_______________.00


I5. Did [you/Name] 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


I6. Did [You/NAME] 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


I7. Did [You/NAME] receive any survivor or disability income during the past month?

  1. Yes

  2. No

[IF yes]

I7b. What was the amount?

$_______________.00


I8. Did {you/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 during the past month?

  1. Yes

  2. No

[IF yes]

I8b. What was the amount?

Do not include Social Security.

$_______________.00


I9. Did {You/NAME} 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


I10. Did [you/NAME] 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:]

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/name] 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 I13A.

[End loop]


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. $,2751 to $,4250

  4. $4,251 or more


I14. Thank you very much for completing this questionnaire. You’ve earned a $X incentive for your household.



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

  1. You will receive an email or text message directing you to our training videos for the food log.

  2. Please watch the training videos for information on how to complete the food log.

  3. Once you complete the food log you will receive an additional $XX.


These are the next steps for your household members:

  1. Your household members over the age of XX will receive an email or text invitation to participate in this study.

  2. Once they complete their survey, they will receive $XX.



Submit Button


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