Field Test of the National Household Food Acquisition and Purchase Survey

APPENDIX G
CHANGES TO HOUSEHOLD INTERVIEW #1

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National Household Food Acquisition and Purchase Survey: Interview 1

Mathematica Policy Research
I also want to stress that all the information you provide is completely
confidential. [SIPP04wc1, BEGINT]

HOUSEHOLD INTERVIEW #1
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 19 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.

A1. I need to make a list of all the people who are living or staying here at this
address over the next week or two. Be sure to include:
- People who stay here only some of the time,
- non-relatives who live here,
- and of course any babies and small children.

INTERVIEWER: ENTER HOUSEHOLD SIZE FROM SCREENER

Please mention someone even if you're not sure they should be included.
Let's start with you. What is your name?

|___|__ |HOUSEHOLD SIZE
INTRODUCTION (Note: this interview follows screener)

INTERVIEWER: ENTER FIRST NAME AND SEX IN RESPONDENT ROW.

As I said earlier, taking part in this study is completely voluntary. The
information you give us is strictly confidential. Your name will not be attached
to any of your answers. Your name and responses will not be shared with
anyone and your responses will not have any effect on services you may now
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 always call the telephone
number in the letter and brochure.

First
Name

Sex

Relationship
to R

Household
member, absent
1
at time of survey

Non-household member,
staying in sample unit at
2
time of survey

1

Absent household members will be included on roster for questions about demographics and
income; these members do not receive food diaries.

2

Non-household members will be included on roster for questions about demographics, but not
income; these non-members will receive food diaries if they reside with the household for the full
data collection week.

Now I’d like to ask you about the people living in your household, where you
usually shop for food, and food programs you may participate in. It will take
about [IF HHSIZE 1-2=15, IF HHSIZE >2 = 30] minutes to answer these questions.

Please give me the names of everyone else who lives or stays here most of
the time. Anyone else? [SIPP04W1C, PREROST]

Is now a good time to do the interview? I’d like to continue now unless you
have any questions for me.
(1)
YES  CONTINUE
(0)
NO
SECTION A.

INTERVIEWER: ENTER FIRST NAME IN ROSTER. ENTER SEX AND
RELATIONSHIP IF OFFERED.
IF ONE PERSON IN HOUSEHOLD, SKIP TO A3. ELSE ASK:

HOUSEHOLD ROSTER

We will begin the interview with questions about who lives here.
READ AS NEEDED: I understand that you may have already provided some of
this information, but I need to read the whole series of questions on this sheet.

1

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National Household Food Acquisition and Purchase Survey: Interview 1

Mathematica Policy Research
A6. How old is NAME?

A5. What is NAME’s relationship to you?
[SIPP04W1C, RELRP]

|__|__|__| ENTER AGE IN YEARS
A6a.IF UNDER 18 – What is NAME’s month and year of birth?

[NEED TO ADD CAPI VALIDATION CHECKS ON RELATIONSHIP CODES. SEE SIPP.]
|__|__| MONTH
|__|__|__|__| YEAR
(0) Respondent
(1) Spouse
(2) Unmarried Partner
(3) Child/Step-child/Adopted child
(4) Grandchild
(5) Parent
(6) Brother/Sister
(7) Other Relative (e.g uncle, cousin, in-law)

(8) Foster Child
(9) Housemate/Roommate
(10) Roomer/Boarder
(11) Other non-relative
(77) REFUSED
(99) DON’T KNOW

CAPI CHECK: NEED AT LEAST ONE PERSON IN THE HOUSEHOLD AGE 18
YEARS OR OLDER, ELSE END INTERVIEW. IF NO ONE AGE 18 AND OLDER,
INTERVIEWER READS: I’m sorry, your household is not eligible for the
study. We need to speak with someone age 18 or older.
FOR A7-A8, ASK EACH QUESTION (WITH FOLLOW-UP, IF APPLICABLE)
FOR EVERY NAME ON ROSTER, THEN MOVE TO NEXT QUESTION.

A7. (Are you/Is NAME) Spanish, Hispanic, or Latino? (How about/And) NAME?
READ IF NECESSARY: such as Mexican, Mexican-American, Chicano, Puerto
Rican, Cuban, or some other Spanish, Hispanic, or Latino group.
[SIPP04W1C, ORIGIN]
(1) No, not Spanish, Hispanic, or Latino
(2) Yes, Mexican, Mexican American, or Chicano
(3) Yes, Puerto Rican
(4) Yes, Cuban
(5) Yes, other Spanish, Hispanic, Latino
(77) REFUSED
(99) DON’T KNOW

4

APPENDIX I
CHANGES TO SINGLE BOOK FOR REPORTING
FOOD ACQUISITIONS

OMB Control Number:
Expiration Date:

The U.S. Department of Agriculture’s

The National Food Study

Household Food Book
Don’t forget to include foods acquired by all participating
household members.

First Day: _________________________________
   Last Day: _________________________________ 
Your household has been selected at random to participate in this study. Each household member
should decide whether or not to participate. If you agree to participate, we ask you to keep track of
the foods that you get away from home for 7 days and to save receipts from your food purchases.
It will take about one hour of your time during the week and you will get a gift card at the end of
the week. Participation 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. If you decide not to take
part it will not affect any benefits or services received by anyone in your household. If over

age 10, please initial next to your name if you agree to take part in this study.

Name

Initials

1 _______________________________

_____

2 _______________________________

_____

3 _______________________________

_____

4 _______________________________

_____

5 _______________________________

_____

6 _______________________________

_____

APPENDIX K
CHANGES TO ADULT FOOD BOOKLET

OMB Control Number:
Expiration Date:

The U.S. Department of Agriculture’s

The National Food Study
Foods You Eat-Out and Take-Out
Adult Booklet

First Day: _________________________________
   Last Day: _________________________________ 
Booklet for: _________________________________

Your household has been selected at random to participate in this study. If you agree to
participate, we ask you to keep track of the foods that you get away from home for 7 days and to
save receipts from your food purchases. It will take about one hour of your time during the week
and you will get a gift card at the end of the week. Participation 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. If you decide not to take part it will not affect any benefits or services received by
anyone in your household. Your information will be kept private and will not be released in a
form that might identify you.

Please sign below if you agree to take part in this study.

 Signature: _________________________________ 

APPENDIX L
CHANGES TO YOUTH FOOD BOOKLET

OMB Control Number:
Expiration Date:

The U.S. Department of Agriculture’s

The National Food Study
Youth Booklet
For foods you get when not with a parent or guardian

 First Day: ______________________ 
 Last Day: ______________________ 
Booklet for: _________________________
Your household has been selected at random to participate in this
study. If you agree to participate, we ask you to keep track of the
meals and snacks that you get away from home for 7 days and to save
receipts from your food purchases. It will take about one hour of your
time during the week and you will get a gift card at the end of the
week. Participation 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.

Please sign below if you agree to take part in this study.

Signature: _________________________

About the Study
The National Food Study is collecting information from households
throughout the United States. This study will answer questions like:





Where do people get their food?
What types of food do people get?
How often do people get food?
How much money do people spend on food?

Your family has agreed to take part in this national study.

Help us make sure that kids count!
We need your help!
For the next week we want you to keep track of all the foods and
drinks you buy or get for free.


Use this book to track foods and drinks that you get when you
are not with a parent or guardian



Give your book to your parent or guardian on days 2, 5, and 7
when they call us to report the foods your family got



Get a gift card at the end of the week for completing this book



Help us to make the National Food Study a big success!

Remember … the information that you provide will be kept confidential. Your
name will be removed from your book after it is received. Your answers, and all
the information provided by your household, will be grouped with others.

Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food

Mon

√ Tue

Wed

Thu

Fri

Sat

Sun

Name of PLACE  
where you got   McDonalds 
food:
(√) CHECK the
meal or snack

TOTAL PAID
(including tax)

Breakfast

$

Lunch

3  6 6 

√ Dinner/Supper

Snack/drink

(√) if free

Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)

Amount
paid

French fries 

Large 

1 

$1.89 

Coke 

Large 

1 

$1.59 

QUESTIONS? Call 1-866-275-8659

APPENDIX N
CHANGES TO HOUSEHOLD INTERVIEW #2

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National Household Food Acquisition and Purchase Survey: Interview 2  

Mathematica Policy Research 

SECTION A. NON‐FOOD EXPENDITURES 
We’re going to start with some questions about your household expenses.  

CASE ID:__________

A1. Are your living quarters …   

HOUSEHOLD INTERVIEW #2

[SIPP] 

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 

(1)  Owned or being bought by you or someone in your household  
SKIP TO A2 
(2)  Rented, or  
(3)  Occupied without paying rent?  SKIP TO A4 
(77)REFUSED  SKIP TO A1b 
(99)DON’T KNOW  SKIP TO A1b 

A1a. How much did (you/your household) pay for rent last month? 

  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 26 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  

As you may remember, this study is designed to help the U.S. Department 
of Agriculture understand households’ food choices and America’s food 
needs. To understand households’ food choices, we need to gather detailed 
information about households’ financial situations. In this interview I’ll ask 
you about household expenses, income, and assets – which include things 
you own or money you may have saved.  

Taking part in this study is voluntary ‐ you can skip any question you do not 
want to answer or that makes you feel uncomfortable. 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 affect any benefits or services you may receive from any other 
government agency, now or in the future. It will take about 30 minutes to 
answer these questions.  

Is now a good time to do the interview? I’d like to continue now unless you 
have any questions for me.  

(1)  
YES  CONTINUE 
(0)  
NO   

$|__|__|__|__|.|__|__| 
(77)REFUSED  
(99)DON’T KNOW  

A1b. Is this public housing – that is, is it owned by a local public housing 
authority or other public agency? DO NOT INCLUDE MILITARY 
HOUSING [SIPP] 
(1)  YES  SKIP TO A4 
(0)  NO   
(77)REFUSED  SKIP TO A4 
(99)DON’T KNOW  SKIP TO A4 

A1c. Is the rent here subsidized by the Federal, State, or Local 
government? By that I mean, is the government paying part of the 
cost?   DO NOT INCLUDE MILITARY HOUSING 

(1)  YES SKIP TO A4 
(0)  NO   SKIP TO A4 
(77)REFUSED  SKIP TO A4 
(99)DON’T KNOW SKIP TO A4 
1 

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National Household Food Acquisition and Purchase Survey: Interview 2

Mathematica Policy Research
A20. How much (do you/does your household) pay in car/truck payments
for [YEAR] [MAKE] [MODEL]?

A18. How many cars, trucks, minivans, vans or SUVs (do you/ does your
household) have? Do not include vehicles used entirely for business.

$|__|__|__|__|.|__|__|

|__|__| NUMBER
(0) NONE  SKIP TO A26
(77) REFUSED  SKIP TO A26
(99) DON’T KNOW  SKIP TO A26

(77) REFUSED
(99) DON’T KNOW
A20a. ASK IF NECESSARY: What period is covered by each payment?

A18a. What are the years, makes, and models of each vehicle?
# Year

Make

(0) WEEK
(1) 2 WEEKS
(2) MONTH
(3) QUARTER
(4) SEMIANNUALLY
(5) ANNUALLY
(6) ONE TIME PAYMENT
(7) OTHER, SPECIFY: _______________________
(77) REFUSED
(99) DON’T KNOW

Model

1
2
3
(77) REFUSED
(99) DON’T KNOW
FOR EACH VEHICLE ASK:
A19. (Do you/Does your household) own or lease the [YEAR] [MAKE]
[MODEL]?

ASK IF A17 = 0, 77, 99
A21. (Do you / Does your household) have any automobile expenses?
PROBE: Expenses might include gasoline, insurance, parking, rental
cars, or expenses for tolls.

(1) OWN
(2) LEASE SKIP TO A20
(77) REFUSED
(99) DON’T KNOW

(1) YES
(0) NO  SKIP TO A26
(77) REFUSED  SKIP TO A26
(99) DON’T KNOW  SKIP TO A26

A19a. Approximately how many monthly payments are left on [YEAR]
[MAKE] [MODEL]?

A22. What is (your / your household’s) average monthly expense for
gasoline and other fuels (including gasohol) for all vehicles?

PROBE: How many monthly payments are needed to pay off the
vehicle?

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

|__|__| MONTHLY PAYMENTS LEFT
(0) NONE SKIP TO A22
(77) REFUSED
(99) DON’T KNOW
9

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National Household Food Acquisition and Purchase Survey: Interview 2

Mathematica Policy Research

B5. For the following types of income, just tell me yes or no, did (you /
anyone in your household) receive income from any of the
following in [LAST MONTH]? CHECK ALL THAT APPLY.

SECTION C. UNEARNED INCOME
C1. I have another list of income sources. Again, just tell me yes or no,
did (you / anyone in your household) receive income from any of
the following in [LAST MONTH]? CHECK ALL THAT APPLY

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)

Rental properties?
Roomers or boarders?
Job training, work study, or internship?
Strike benefits?
Workers’ compensation?
Unemployment compensation?
Provision of day care services in the home?
Sale of home-prepared food (such as sandwiches, beverages,
baked goods) from a kiosk or truck, or to another vendor?
(9) Catering?
(10)NONE
(77)REFUSED
(99)DON’T KNOW

(1) Social Security Retirement Benefits (SSA)
(2) Social Security Disability Benefits also known as SSDI
(3) Supplemental Security Income or SSI
(4) Temporary Assistance for Needy Families (TANF/STATE NAME)
(5) General Assistance, General Relief, or the GA program
(6) Veteran’s benefits or military allotments
(7) Black Lung Benefits
(8) Child support
(9) Alimony
(10)Foster Care
(11)Pensions, civil service annuities, retirement benefits, survivor’s
benefits, or Railroad Retirement Benefits
(12)Interest, dividends, or capital gains income
(13)Money from a person who is not in your household (not
alimony or child support)
(14)Educational grants, loans, or stipends
(0) NONE SKIP TO C2
(77)REFUSED SKIP TO C2
(99)DON’T KNOW SKIP TO C2

FOR EACH INCOME REPORTED IN B5, ASK:
B5a. How much was received from [INCOME] in [LAST MONTH]?
$|__|__|__|__|__|.|__|__|
(77) REFUSED  SKIP TO B6
(99) DON’T KNOW  SKIP TO B6
B5b. ASK IF NECESSARY: Was that weekly, every other week, two times per
month, or monthly?
(1) DAILY
(2) WEEKLY
(3) EVERY OTHER WEEK OR BI-WEEKLY
(4) TWO TIMES PER MONTH
(5) MONTHLY
(77)REFUSED
(99)DON’T KNOW

C1a. FOR EACH INCOME REPORTED IN C1, ASK: How much was
received from [INCOME] in [LAST MONTH]?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
ENTER ‘C’ FOR A COMBINED INCOME
13

APPENDIX O
CHANGES TO HOUSEHOLD INTERVIEW #3

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National Household Food Acquisition and Purchase Survey: Interview 3

Mathematica Policy Research

|___|___| ENTER NUMBER  
(0)    NEVER   
(77) REFUSED 
(99) DON'T KNOW  

CASE ID: ______________________

HOUSEHOLD INTERVIEW #3

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 18 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. 

IF HHSIZE=1 SKIP TO A3. 

A2. IF  HHSIZE>1:  During  the  past  7  days,  how  many  meals  did  all  or  most  of 
your family sit down and eat together?  
[NHANES, CBQ.180] 
PROBE: This includes meals eaten away from home. 

In this interview I’ll ask you about your household’s eating habits, dietary 
needs, and general health status.  

 According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a 

|___|___| ENTER NUMBER  
(0)    NONE   SKIP TO SECTION B  
(77) REFUSED   SKIP TO SECTION B 
(99) DON'T KNOW   SKIP TO SECTION B 

Taking part in this study is completely voluntary. You can decide to take part or 
not. You can skip any question you do not wish to answer or that makes you 
feel uncomfortable. 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 affect any benefits or services you may 
receive from any government agency, now or in the future. It will take about 30 
minutes to answer these questions. At the end of this interview, I will collect all 
booklets, receipts, magnet, and the scanner. 

It will take about 30 minutes to answer these questions. Is now a good time to 
do  the  interview?  I’d  like  to  continue  now  unless  you  have  any  questions  for 
me.  
(1)   YES  CONTINUE 
(0)   NO    

Section A. Consumer Behavior

A3. During  the  past  7  days,  did  any  guests  come  to  your  home  for  a  meal  or 
snack? 

(1)  YES 

(0)   NO  SKIP TO B1 

(77)  REFUSED  SKIP TO B1 

(99)  DON'T KNOW SKIP TO B1 

A3a.  How  many  times  last  week  did  guest(s)  come  to  your  home  for  a 
meal or snack? 

|___|___| ENTER NUMBER 
(77) REFUSED   
(99) DON'T KNOW   

A1. During  the  past  7  days,  how  many  times  did  you/someone  else  in  your 
family) cook food for dinner or supper at home? This includes time spent 
putting the ingredients together to cook a meal. Do not include heating up 
leftovers or frozen meals.  
[NHANES, CBQ.160] 

1

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National Household Food Acquisition and Purchase Survey: Interview 3
Section F. Previous Residence

Mathematica Policy Research

F3. Were (you / NAME) born in [STATE FROM F2a OR STATE FROM SAMPLE]?

My last questions are about your current and previous residence.
ASK QUESTIONS F1‐F4 FOR ALL ADULTS IN HOUSEHOLD.
F1. When did (you / NAME) move into this (house / apartment / mobile home),
that is, in what year?

(1) YES  SKIP TO F4
(0) NO
(r) REFUSED
(d) DON'T KNOW

IF LIVED HERE MORE THAN ONCE, ENTER YEAR OF MOST RECENT MOVE.

F3a. Where were (you / NAME) born?
[PICK FROM LIST OF STATES]  SKIP TO NEXT ADULT IN HH LOOP
(72) NOT IN THE U.S.
(r) REFUSED
(d) DON'T KNOW

(A) Always lived here
|__|__|__|__| YR  SKIP TO F2
(r) REFUSED  SKIP TO F2
(d) DON'T KNOW  SKIP TO F2

IF BORN OUTSIDE US (F3a=NOT IN U.S.):
F3b. Are (you /is NAME) a U.S. citizen? PROBE: We are not interested in
your immigration status. We are asking about citizenship because it
helps to determine whether people are eligible for Food Stamps.

F1a. So (you / NAME) lived here since birth ‐ is that correct?
(1) YES
(0) NO – SKIP TO F3a
(r) REFUSED – SKIP TO F3a
(d) DON'T KNOW – SKIP TO F3a

(1) YES
(0) NO
(r) REFUSED
(d) DON'T KNOW

F1 NOT ALWAYS LIVED HERE
F2. Was (your /NAME’S) previous home also located in [STATE], or was it in
some other state?

END: That completes your final interview. Thank you for taking the time to
answer these questions.

(1) YES, SAME STATE  GO TO F3
(0) NO, NOT IN THE SAME STATE
(r) REFUSED
(d) DON'T KNOW
F2a. ASK IF NECESSARY: What state was that?
|__|__|[PICK FROM LIST OF STATES]
(66) NOT IN THE U.S. – GO TO F3a
(r) REFUSED – GO TO F3a
(d) DON'T KNOW – GO TO F3a

10