Form 1 Demographic Questionnaire

Generic Clearance for Questionnaire Pretesting Research

Appendix H Demographic Questionnaire revision 20240712

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

OMB: 0607-0725

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Appendix H: Demographic Questionnaire



Demographic Questionnaire



1.

What is your age? _________


2. What is the highest level of school education you have completed?

Shape1 Less than high school diploma

Shape2 High school diploma

Shape3 Some college courses, no degree

Shape4 Associate’s degree

Shape5 Bachelor’s degree

Shape6 Graduate degree


3. What is your current gender?

Shape7 Woman

Shape8 Man

Shape9 Nonbinary

Shape10 Another gender identity (free text write-in)



4. What is your race/ethnicity? (choose all that apply)

Shape11 White

Shape12 Black or African American

Shape13 Hispanic or Latino

Shape14 American Indian or Alaska Native

Shape15 Asian

Shape16 Native Hawaiian or Other Pacific Islander

Shape17 Other: _____________________


5. Did you or anyone in your household receive WIC benefits in the past 30 days? WIC is short for the Special Supplemental Food Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5.


Yes

No


6. Did you or anyone in your household get SNAP or government assistance for food purchases in the past 30 days? SNAP stands for Supplemental Nutrition Assistance Program and was formerly known as the Food Stamp Program. SNAP benefits are provided on a food stamp benefit card/EBT card.


Yes

No


7. How long have you been using a smartphone? (Check one of the following)


Less than 1 year (STOP RECRUITMENT)

1 year or more but less than 2 years

2 years or more


8. How often do you use a smartphone in a week? (Check one of the following)


Everyday

5-6 days

3-4 days

1-2 days

Less than 1 day


9. List up to three things you do most often on your smartphone, for example, making a phone call.


1. _________________________________

2. _________________________________

3. _________________________________


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorRidolfo, Heather - REE-NASS, Washington, DC
File Modified0000-00-00
File Created2025-08-12

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