Non respondents

APPENDIX E
SHORT FORM FOR NONRESPONDENTS

OMB # place holder
National Food Study

Mathematica Policy Research

SHORT FORM FOR HOUSEHOLDS NOT INTERESTED IN PARTICIPATING IN THE STUDY
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required
to complete this information collection is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

FORMAT: Conducted on paper via in-person interview.
I respect your decision not to take part in this study. It is completely voluntary. I would like to ask a few questions that will
help us provide the U.S. Department of Agriculture with important information about the households in this area, including
those who choose not to participate in our study. These questions will take less than five minutes of your time.
May I begin?
1.

3.

Where do you do most of your food shopping?
PROBE: Where do you spend the most money
shopping for food?

YES
NO
77 REFUSED
99 DON’T KNOW
1

NAME OF STORE: __________________________

0

1a. ASK IF NECESSARY: What type of store is that? Is
it a …
1 Supermarket
2 Small grocery store
3 Convenience store (7-11/MiniMart)
4 Dollar store
5 Discount or big box store like Kmart, Target, or
Walmart
6 Wholesale club like Costco, B.J.’s, or Sam’s Club
7 Other
8 REFUSED
9 DON’T KNOW
2.

4.

How many people live in your household in total,
including yourself?
_________ HH NUMBER

5. How many people in your household are …

In the past 30 days did you purchase food from a …
Yes

During the past 30 days, did you or anyone in your
household go to a food pantry or food bank for
groceries?

No

DK

a. Supermarket

1

0

9

b. Small grocery store

1

0

9

c. Convenience store

1

0

9

d. Dollar store

1

0

9

e. Discount or big box store like
Kmart, Target, or Walmart

1

0

9

f. Wholesale club like Costco,
B.J.’s, or Sam’s Club

1

0

9

g. Specialty store such as bakery,
meat or fish market

1

0

9

h. Pharmacy or drug store

1

0

9

Children under age 5

# _____

Children in elementary school

# _____

Children in middle school / junior high

# _____

Children in high school

# _____

Adults over 18 years old

# _____

CHECK THAT TOTAL IN Q5 = Q4

Those are all the questions I have for you. Thank you for
your time. If you change your mind about taking part in
the study, please call us at the toll-free number on the
brochure.
HAND BROCHURE.
Have a nice day!

1