Elderly & Working Poor

OMB Number: 0584-0558

Expiration Date: 10/31/2013

Date: ­­­­­­­­­____________

Evaluation of Reaching the Underserved Elderly and Working Poor in SNAP Telephone Screener

SCREENER FOR ELDERLY

RECRUIT 20 PEOPLE TO SEAT 10-15

Public reporting burden for this screener is estimated to average 5 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0558).

ASK FOR PERSON NAMED ON SNAP LIST

Hello. My name is ____________________, and I'm calling from Mathematica Policy Research, a private research organization. We are conducting a study in [SITE] for the U.S. Department of Agriculture on the Supplemental Nutrition Assistance Program (SNAP), or Food Stamp Program in [SITE]. You may know this program as [local SNAP name]. We are located in Washington, DC and are not from the [local SNAP office name] or from any local organization that you may have already spoken with about [local SNAP name].

[Michigan, Pennsylvania]: We were given your name by the state [Michigan: Food Assistance Program; Pennsylvania: Department of Public Welfare] specifically to conduct this research so that the government can improve this program for older persons age 60 and older.

[Ohio]: We were given your name by the Ohio Department of Job and Family Services specifically to conduct this research so that the government can improve this program for older persons age 55 and older.

Let me assure you that this is not a sales call and at no time during our discussion will you be asked to donate money. We would simply like to see if you may be eligible to participate in a group discussion about [local SNAP name] for our study.

I would like ask just a few questions today. If you are able to participate, the group discussion will take place at [PLACE] on a different day. If you attend the group decision, you will be given $40 in cash for participating and to cover the cost of your transportation to the group discussion. And we will provide some light refreshments.

The questions I will ask today will only be used to identify some people to participate in our discussion group, and the answers you give me will not be shared with anyone outside of our research team, except as required by law. Your answers to these questions will not affect any benefits you receive from the government.

May I ask you some questions to help determine whether you are eligible for our study?

¨ Yes CONTINUE

¨ No.............................................................................................THANK AND TERMINATE

RECORD GENDER:

¨ Female ¨ Male

RECRUIT A MIX OF GENDERS

1. When was the last time you applied for food stamps through (local name)? Would you say it was within the last month, between one and three months, or longer than three months ago?

¨ Less than one month

• Between one and three months

¨ Longer than three months ago (THANK AND TERMINATE)

¨ Never (THANK AND TERMINATE)

2. Which of the following categories includes your age?

¨ 18-34 (THANK AND TERMINATE)

¨ 35-44 (THANK AND TERMINATE)

¨ 45-54 (THANK AND TERMINATE)

¨ 55-59 (EXCEPT IN OHIO – THANK AND TERMINATE)

¨ 60 -69

¨ 70 or older

RECRUIT A MIX OF GENDERS AND AGES OVER 60 (OVER 55 IN OHIO)

3. Do you consider yourself to be of Hispanic or Latino/a origin?

PROBE: Hispanic or Latino/a origin includes, Mexican American or Chicano/a, Puerto Rican, Cuban, and Central or South American?

¨ Yes, Hispanic or Latino/a origin

¨ No

4. What race do you consider yourself? (CHECK ALL THAT APPLY)

(IF R SAYS HISPANIC OR LATINO, JUST WRITE RESPONSE IN THE MARGIN)

¨ American Indian or Alaska Native

¨ Asian

¨ Black or African American

¨ Native Hawaiian or Other Pacific Islander

• White

5. What language are you most comfortable speaking?

• English

• Spanish

• Other

6. (INTERVIEWER: ASK ONLY IF NECESSARY BASED ON FLOW OF INTERVIEW TO THIS POINT) How well would you say you understand and speak English? (READ CATEGORIES)

• Not at all (THANK AND TERMINATE)

• Not well (THANK AND TERMINATE)

• Well

• Very Well

IF YOU DETERMINE THE RESPONDENT WOULD NOT BE A GOOD CANDIDATE FOR THE FOCUS GROUP BASED ON HIS/HER ABILITY AND WILLINGNESS TO COMMUNICATE OPENLY, THANK AND TERMINATE:

Thank you for talking with me today. If we need you for the Discussion Group, we will call you back. I appreciate that you took the time to answer my questions.

INVITATION

Thank you for answering all of my questions. As part of our study, we are conducting a discussion group related to food stamp or [local SNAP name].

• [Michigan, Pennsylvania] The purpose of the study is to learn about your experiences in order to make the program better for people who are age 60 and older. As mentioned earlier, we will not try to sell you anything or use your name for other purposes than this research. After the discussion, any personal information we have about you, including your name and phone number, will be destroyed.

• [Ohio] The purpose of the study is to learn about your experiences in order to make the program better for people who are age 55 and older. As mentioned earlier, we will not try to sell you anything or use your name for other purposes than this research. After the discussion, any personal information we have about you, including your name and phone number, will be destroyed.

The group will consist of approximately 10 other people, such as yourself, and a discussion leader from Mathematica; nobody from the [local SNAP office name] or from any local organization that you may have already spoken with about [local SNAP name] will be at the discussion. You are invited to attend the group that will take place at 12:00 p.m. on DAY, DATE. It will be held at the PLACE. The group will last 1 ½ hours. You will be given $40 in cash as a token of our appreciation and to offset your transportation costs. Refreshments will also be served. Would you be able to attend?

¨ YES…………………………CONTINUE WITH “MORE INFORMATION” BELOW

¨ NO…………………………………………. THANK AND TERMINATE

MORE INFORMATION

Please make sure that if you need glasses or other corrective lenses that you bring them or wear them to the session. There may be some materials that you will have to read and/or look at. Also, if you use hearing aids, be sure to bring them so that you can participate in all aspects of the discussion.

So that we can start and end on time, please plan to arrive about 15 minutes early to meet the other participants and have refreshments.

We are counting on your participation, so please be sure to call Susanna Fernandes in our office as soon as possible if you find you can't attend so we can find a replacement. The phone number here is 800-340-2577.

Before we finish, let me make sure I have the correct spelling of your name and also get your address and phone number(s) so that we can send you a confirmation letter with directions and give you a reminder phone call.

FIRST AND LAST NAME: ________________________________________________

HOME PHONE: ________________________________________________________

ADDRESS ____________________________________________________________

PERSONAL E-MAIL ADDRESS: ___________________________________________

WORK PHONE:_________________________________________________________

CELL PHONE:__________________________________________________________

Thank you very much for your time today. We look forward to meeting you at the discussion group and learning about your experiences with the SNAP/FS program. We’ll see you there!

Recruiter’s name _______________________________ Date____________________

Confirmed by __________________________________ Date_____________________

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