Field Test of the National Household Food Acquisition and Purchase Survey

APPENDIX D
HOUSEHOLD SCREENER

CASE ID: |____|____|____|____|____|____|____|____|

OMB: XXXXXXXXXX

National Household Food Acquisition and Purchase Survey
Mathematica Policy Research – Household Screener
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.

INTRODUCTION

Hello, I’m [FILL NAME]. I work for Mathematica Policy
Research and we’re conducting a survey for the U.S.
Department of Agriculture.

The addresses we visit have been scientifically selected
to represent all households in our country. If you are
eligible, you can start the study today and you’ll receive
at least

SHOW ID CARD
We recently sent a letter to this address explaining the
survey, which is called the National Food Study. This
study looks at the foods households get over the course
of a week, and will help answer questions about how
much households spend on food, where they get food
and how much they pay for food.
This information will help the USDA improve its
programs and ensure that all Americans have access to
a healthy diet at affordable prices.
1. Did you get our letter?
1

 Yes

0

 No

d

 DON’T KNOW

r

 REFUSED

SHOW THE LETTER AND BROCHURE AGAIN, AND
OFFER THEM TO THE POTENTIAL INTERVIEWEE.

CIRCLE INCENTIVE: $50 (LOW); $100 (HIGH)

for completing all of the survey activities for one week.
I need to ask you some questions to find out if your
household is eligible for the survey. Taking part is
voluntary. We are required by law to use your
information for statistical research only and to keep it
confidential. The law prohibits us from giving anyone any
information that may identify you or your family without
your consent. Your responses will not have any effect on
services you may receive or may apply for in the future.
You also do not have to answer any questions that make
you feel uncomfortable. There are no risks for
participating but if you have any questions you can call
the telephone number in the letter and brochure.
It will take about 10 minutes to answer these questions.
Do you have any questions before we start?
1A. May I begin?
1
2

 YES
 NO

GO TO Q.2
PROVIDE MORE INFO ABOUT
STUDY AND TOTAL INCENTIVES.
IF REFUSAL, THANK AND
TERMINATE.

VERIFY ADDRESS
2. I have this address listed as [READ ADDRESS FROM CONTACT SHEET]. Is that your exact address?
1

 YES, EXACTLY CORRECT AS LISTED

2

 MOSTLY CORRECT, BUT NEEDS SOME MINOR CHANGES

3

 INCORRECT ADDRESS

GO TO Q.3
MAKE CHANGES ON CONTACT SHEET

TERMINATE INTERVIEW AND FIND CORRECT ADDRESS
Page 1

3. Is your mailing address the same as your street address? Do you get your mail sent to this address?
1

 Yes

0

 No

d

 DON’T KNOW

r

 REFUSED

GO TO Q.4 ON NEXT PAGE

GO TO Q.4

3a. Please give me your complete mailing address (including apartment number).
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:

STATE:

ZIP:

4. Are there any other housing units or living quarters—either occupied or vacant—at this address? A separate
housing unit has either (1) direct access from the outside or from a common hallway, or (2) a kitchen or
cooking equipment for the exclusive use of the occupants.
1

 Yes, one other unit

2

 Yes, more than one other unit

0

 No

d

 DON’T KNOW

r

 REFUSED

GO TO Q.5

4a. What is the exact address of the (first) unit or living quarters?
1

 SAME

0

 NOT SAME

d

 DON’T KNOW

r

 REFUSED

WRITE ADDRESS BELOW
GO TO Q.4b

FIRST UNIT STREET / P.O. BOX:
UNIT:

CITY:

ZIP:

[IF Q4=2, WRITE ADDITIONAL ADDRESSES ON PG. 7]

4b. Do the occupants of the additional units or living quarters live separately from the people in your household?
1

 Yes

THIS UNIT MUST BE INTERVIEWED
SEPARATELY

0

 No

THIS UNIT IS PART OF THE
HOUSEHOLD. BE SURE TO COUNT THEM IN HOUSEHOLD SIZE.

[IF Q4B=1, CALL SUPERVISOR AFTER COMPLETING THE SCREENER AND BEFORE COMPLETING HOUSEHOLD
INTERVIEW #1 AND TRAINING. SUPERVISOR WILL CHECK IF THE ADDITIONAL UNIT SHOULD BE
INTERVIEWED.]

Page 2

HOUSEHOLD INFORMATION
5. Including yourself, how many people live in your
household? Don’t forget to include non-relatives
who live here and, of course, babies and small
children. Also include persons who usually live
here but are temporarily away for reasons such
as: vacation, traveling for work, or in the
hospital. Do not include children living away at
school.
|
d
r

|

IF HHSIZE = 1, SKIP TO Q.9. ELSE ASK:
8. In a typical week, how many meals do all or most
of the members of your household eat together,
including meals eaten away from home?
|

6. Do all the people in your household live together
and share food?
1

 Yes

0

 No

FILL “HH SIZE BOX” WITH Q5
RESPONSE. SKIP TO Q.7

| ENTER NUMBER

d

 DON’T KNOW

r

 REFUSED

| NUMBER

 DON’T KNOW
 REFUSED

|

0

 NONE

9. In a typical week, how many times (do you/does)
someone in the household) prepare food for
dinner or supper at home? This includes putting
the ingredients together for a meal. Do not
include heating up leftovers.
|
d
r

|

| ENTER NUMBER

0

 NONE

 DON’T KNOW
 REFUSED

6a. How many people live together and share food?
|

|

| NUMBER

 DON’T KNOW
r  REFUSED
d

ENTER IN HH SIZE BOX
HH SIZE BOX

7. How often (do you/does someone) go food
shopping for (yourself/your household)? Would
you say…

2
3
4
5
6
d
r
1

more than once a week,
once a week,
once every two weeks,
once every three weeks, or
once a month or less?
RARELY SHOP FOR FOOD
DON’T KNOW
REFUSED

Page 3

INTERVIEWER:
REFER TO CONTACT SHEET AND CHECK
OPEN QUOTA GROUPS IN BOX AT RIGHT

OPEN QUOTA GROUPS
Group-A

Group-B

Group-C

Group-D

10. Now I am going to ask about the total income for
(you/your household) last month. Please think
about income from all sources such as wages,
salaries, Social Security or retirement benefits,
help from relatives, and so forth. What category
represents the total income for (you/your
household) before taxes last month?
SHOW HAND CARD.
IF NEEDED: Income is important in determining your
eligibility for this study because we need to include a
certain number of households at different levels of
income.
1

 CATEGORY A

2

 CATEGORY B

3

 CATEGORY C

d

 DON’T KNOW

r

 REFUSED

11. Do you or any member of your household
currently receive Food Stamps? It puts money
on the Families First EBT card that you can use
to buy food.
1

 Yes

0

 No

d

 DON’T KNOW

r

 REFUSED

GO TO INTERVIEWER CHECK #1

GO TO INT CHECK #2

INTERVIEWER CHECK #1:
IS QUOTA GROUP-D OPEN?
1

Yes

GO TO “ELIGIBLE”

0

No

GO TO “NOT ELIGIBLE”

INTERVIEWER CHECK #2:
IS THE HOUSEHOLD’S INCOME CATEGORY AN
OPEN QUOTA GROUP?
1

Yes

GO TO “ELIGIBLE”

0

No

GO TO “NOT ELIGIBLE”

Page 4

ELIGIBLE CONTINUE HERE
Thank you. Your household is eligible for the survey! I’d like to continue now and get your complete contact
information and tell you about the survey.
INT: IF LOW INCENTIVE HH

INT: IF HIGH INCENTIVE HH

In total, it may take six to seven hours of time during the
week.

In total, it may take six to seven hours of time during the
week.



The primary food shopper in the household, who is
asked to complete three 30-minute interviews and
keep track of foods they get during the week, will
receive a $50 check at the end of the week.



The primary food shopper in the household, who is
asked to complete three 30-minute interviews and
keep track of foods they get during the week, will
receive a $100 check at the end of the week.



The primary food shopper will also receive up to
three (3) $10 gift cards, one for each time that you
call us to report the foods you get during the week.



The primary food shopper will also receive up to
three (3) $10 gift cards, one for each time that you
call us to report the foods you get during the week.



Other members of your household can also get a gift
card if they report the foods they get during the
week.



Other members of your household can also get a gift
card if they report the foods they get during the
week.

I have a few more questions to see who in your household is the best person to complete the survey.
12. AGREE TO CONTINUE?
1

 Yes

CONTINUE TO Q13 ON NEXT PAGE

0

 No

GO TO SHORT FORM – LAST PAGE
NOT ELIGIBLE CONTINUE HERE

Thank you for your time. I’m sorry your household is not eligible for the study.
19. May I have your name and telephone number in case my supervisor wants to confirm that I spoke with you?
FIRST NAME:

LAST NAME:

TELEPHONE: (______) - ______ - _______________
Area Code

 NO TELEPHONE
 DON’T KNOW
r  REFUSED
0
d

20. WHAT LANGUAGE WAS USED FOR THIS INTERVIEW?
1

 ENGLISH

2

 SPANISH

d

 DON’T KNOW

THANK AGAIN AND TERMINATE
Page 5

IDENTIFY FOOD SHOPPER AND MEAL PLANNER

13. Are you the person who does most of the
planning or preparing of meals in your family?
INTERVIEWER: IF R ANSWERS “SOMETIMES”
OR “50/50,” ENTER YES.

14. Are you the person who does most of the
shopping for food in your family?

1

 Yes

SKIP TO Q.13a

1

 Yes

SKIP TO Q.14a

0

 No

SKIP TO Q.13a

0

 No

SKIP TO Q.14a

d

 DON’T KNOW

d

 DON’T KNOW

r

 REFUSED

r

 REFUSED

GO TO Q.14

13a. What is (your name / the name of the person
who does most of the planning or preparing of
meals)?
FIRST NAME

LAST NAME

GO TO Q.15

14a. What is (your name / the name of the person
who does most of the shopping for food)?

FIRST NAME

LAST NAME

INTERVIEWER CHECK #3:
IS R THE MEAL PLANNER OR FOOD SHOPPER?
1

Yes

CONTINUE WITH SCREENER

0

No

ASK TO SPEAK WITH FOOD SHOPPER

IF FOOD SHOPPER AND MEAL PLANNER ARE NOT THE SAME PERSON, ASK FOR MEAL PLANNER IF FOOD
SHOPPER IS NOT AVAILABLE.
IF FOOD SHOPPER/MEAL PLANNER NOT AVAILABLE, FINISH THE SCREENER TO GET FOOD SHOPPER
CONTACT INFO FROM RESPONDENT.

Page 6

GET CONTACT INFORMATION

15. What is the best telephone number to reach
(you/FOOD SHOPPER) at?

16. Is there another number where (you/FOOD
SHOPPER) can be reached?

(______) - ______ - _______________

(______) - ______ - _______________

Area Code

Area Code

 NO TELEPHONE
d  DON’T KNOW
r  REFUSED

 NO TELEPHONE
d  DON’T KNOW
r  REFUSED

0

0

GO TO Q.17

15a. Is that a home phone, cell phone, work phone,
or some other phone?

2
3
4
5
6
1

GO TO Q.17

16a. Is that a home phone, work phone, or some
other phone?

2
3
4
5
6

CELL PHONE
HOME PHONE
WORK PHONE
RELATIVE’S HOME
NEIGHBOR’S HOME
OTHER

1

CELL PHONE
HOME PHONE
WORK PHONE
RELATIVE’S HOME
NEIGHBOR’S HOME
OTHER

17. What language would (you/FOOD SHOPPER) be
most comfortable using for our interviews?

 English
2  Spanish
3  Other (Specify)
1

18.

Do you have time now to discuss the study
and learn about what you’ll be doing for the
week? This will take a little over an hour.
1

 Yes

CONTINUE TO HH1 AND TRAINING

2

 No

NO. SCHEDULE ALTERNATIVE TIME

3

 No

REFUSED TO PARTICIPATE. SKIP TO
Q.B CONT.

Page 7

SHORT FORM
COMPLETE THIS SECTION ONLY IF THE HOUSEHOLD IS ELIGIBLE AND REFUSES TO TAKE PART.
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. I remind you that we are
required by law to use your information for statistical
research only and to keep it confidential. The law
prohibits us from giving anyone any information that may
identify you or your family without your consent.
These questions will take less than five minutes.
B_Cont.

May I begin?

1

 YES

GO TO Q21

2

 NO

TERMINATE

22. In the past 30 days did you purchase food from
a…
YES
a. Supermarket
b. Small grocery store
c. Convenience store
d. Dollar store
e. Discount or big box store
like Kmart, Target, or
Walmart
f. Wholesale club like Costco,
B.J.’s, or Sam’s Club
g. Specialty store such as
bakery, meat or fish market

21. Where do you do most of your food shopping?
PROBE: Where do you spend the most money
shopping for food?
NAME OF STORE:

______________________________________

21a. ASK IF NECESSARY: What type of store is
that? READ RESPONSE CATEGORIES IF
NECESSARY
1

 SUPERMARKET

2

 SMALL GROCERY STORE

3

 CONVENIENCE STORE (7-11 / MINIMART)

4

 DOLLAR STORE

5

 DISCOUNT OR BIG BOX STORE (KMART,
TARGET, OR WALMART)

h. Pharmacy or drug store

DON’T
KNOW

NO

1



0



d



1



0



d



1



0



d



1



0



d



1



0



d



1



0



d



1



0



d



1



0



d



23. During the past 30 days, did you or anyone in
your household go to a food pantry or food bank
for groceries?
1

 Yes

0

 No

d

 DON’T KNOW

r

 REFUSED

24. How many people in your household are…

Children under age 5 ........................... # _____
Children in elementary school ............. # _____
Children in middle school/junior high .. # _____

 WHOLESALE CLUB (COSTCO, B.J.’S OR
SAM’S CLUB)

Children in high school ........................ # _____

7

 OTHER

Adults over 18 years old ...................... # _____

d

 DON’T KNOW

r

 REFUSED

6

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. Have a nice day
Page 8