Household Screener

APPENDIX F
HOUSEHOLD SCREENER AND HAND CARDS

This page has been left blank for double-sided copying.

MPRID: |____|____|____|____|____|____|____|____|

OMB: xxxx-xxxx

National Food Study – 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 less than 5 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. My name is [FILL NAME]. I work for Mathematica
Policy Research and we’re conducting a survey for the
U.S. Department of Agriculture.
SHOW ID CARD

The addresses we visit were scientifically selected to
represent all households in the country. I am here to see
if you are eligible and interested in participating.
Please accept this $5 as a token of our appreciation for
considering this important survey.

We recently sent a post card to this address explaining
the survey, which is called the National Food Study.

If your household is eligible and you participate you will
receive $100 or more for completing the survey
activities.

1. Did you get our post card?

0
d
r
1

OFFER UNCONDITIONAL $5 INCENTIVE

YES
NO
DON’T KNOW
REFUSED

I need to ask you some questions to find out if you are
eligible for the survey. Eligibility is based on household
size, program participation, and income. It will take less
than 5 minutes to answer these questions.

OFFER THE STUDY BROCHURE
This study is about food in the United States. We are
looking at the foods households get over the course of a
week, in order to understand where households get food
and how much they pay for food. This information will
help the USDA improve its programs and ensure that all
residents of the U.S. have access to a healthy diet at
affordable prices.

Taking part is completely voluntary. We are required by
law to use your information for statistical research only
and to keep it confidential. Your responses will not have
any effect on services you may receive or may apply for
in the future.
Do you have any questions before we start?

OBTAIN PERMISSION
2. May I begin?
 YES
0  NO
1

PROVIDE MORE INFO ABOUT STUDY AND INCENTIVES. IF REFUSAL, THANK AND TERMINATE.
STATUS ON CONTACT SHEET 220.

VERIFY ADDRESS
3. I have this address as [READ ADDRESS ON CONTACT SHEET]. Is that your exact address?
 YES. EXACTLY AS LISTED
GO TO Q.4
2  MOSTLY CORRECT, BUT NEEDS MINOR CHANGES
MAKE CHANGES ON CONTACT SHEET
3  INCORRECT ADDRESS
TERMINATE INTERVIEW AND FIND CORRECT ADDRESS
1

Page 1

4. Is your mailing address the same as your street address? Do you get your mail sent to this address?


d
r
1
0

YES
GO TO Q.5
NO
DON’T KNOW
REFUSED

GO TO Q.5

4a. Please give me your complete mailing address (including apartment number).
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

5. ASK IF ADDRESS APPEARS TO BE A SINGLE-FAMILY DWELLING OR SINGLE DETACHED HOUSE, ELSE
SKIP TO Q6. 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.

2
0
d
r
1

YES, ONE OTHER UNIT
YES, MORE THAN ONE OTHER UNIT
NO
DON’T KNOW
GO TO Q.6
REFUSED

5a. What is the exact address of the (first) unit or living quarters?

0
d
r
1

SAME
NOT SAME
DON’T KNOW
REFUSED

WRITE ADDRESS BELOW
GO TO Q.5b

1ST UNIT:
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

2ND UNIT:
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

Page 2

5b. Do the occupants of the additional units or living quarters live separately from the
people in your household?
1

 YES

0

 NO

THIS IS A SEPARATE UNIT AND WILL BE ELIGIBLE FOR SELECTION IN A
LATER SAMPLE RELEASE.
THIS UNIT IS PART OF THE HOUSEHOLD. COUNT IN HOUSEHOLD SIZE.

6. Do you or a member of your household live or stay at this address year round?

0
d
r
1

YES
GO TO Q.7
NO
DON’T KNOW
REFUSED

GO TO Q.6a

6a. How many months of the year do members of this household stay at this address?
 6 MONTHS OR MORE
0  LESS THAN 6 MONTHS
1

GO TO Q.7
TERMINATE. READ IF NECESSARY: This study only
includes people at their permanent residence. Based on
your responses, you are not eligible for the study at this
time. STATUS ON CONTACT SHEET 024.

HOUSEHOLD INFORMATION
7. Including yourself, how many people live in your household? Don’t forget to include babies, small children,
and non-relatives who live here. 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 people living away at school.
|
d
r

|

| NUMBER

 DON’T KNOW
 REFUSED

8. Do all the people in your household live together and share food?
1
0

 YES
 NO

FILL HH SIZE BOX ON NEXT PAGE WITH Q.7 RESPONSE. SKIP TO Q.9

8a. How many people live together and share food?
|

|

| NUMBER

ENTER IN HH SIZE BOX ON NEXT PAGE

 DON’T KNOW
r  REFUSED
d

Page 3

INTERVIEWER: ENTER HH SIZE AND CHECK OPEN QUOTA GROUPS ON CONTACT SHEET
HH
SIZE

INCOME
CATEGORY

OPEN QUOTA GROUPS
Group-A

Group-B

Group-C

Group-D

9. From now on when we refer to your household we mean the [FILL HH SIZE] people that live together and
share food. The next question is about your household’s income. This card [SHOW INCOME SOURCES HAND
CARD] lists types of income people receive. Please tell me which types of income are received by people in
your household. SNAP BENEFITS ARE NOT COUNTED AS INCOME.
1

 EARNINGS FROM WORK

2

 UNEMPLOYMENT COMPENSATION

3

 WORKERS COMPENSATION

4

 DISABILITY OR SSI

5

 SOCIAL SECURITY

6

 PENSIONS AND RETIREMENT INCOME

 CHILD SUPPORT
8  ALIMONY
9  CASH WELFARE (LIKE TANF OR GENERAL ASSISTANCE)
10  INVESTMENT INCOME
11  OTHER
d  DON’T KNOW
r  REFUSED
7

10. Including your household’s income from [LIST INCOME SOURCES IN Q9], which group (A, B or C)
corresponds to your household total income before taxes? SHOW HAND CARD FOR THE HOUSEHOLD SIZE.

2
3
d
r
1

GROUP A
GROUP B
GROUP C
DON’T KNOW
REFUSED

FILL INCOME GROUP BOX ABOVE AND GO TO NEXT PAGE

GO TO Q.10a

CATEGORIES FOR
Q10a and Q10b

10a. Was it [FILL-Q10a] or more last year?
 YES
GO TO Q.10b
 NO
ENTER “A” IN INCOME CATEGORY BOX ABOVE
d  DON’T KNOW
r  REFUSED
1

0

10b. Was it [FILL-Q10b] or more last year?
 YES
ENTER “C” IN INCOME CATEGORY BOX ABOVE
0  NO
ENTER “B” IN INCOME CATEGORY BOX ABOVE
d  DON’T KNOW
r  REFUSED
1

HH
FILL-Q10a FILL-Q10b
Size
1

$11,000

$20,000

2

$15,000

$27,000

3

$18,000

$34,000

4

$22,000

$41,000

5

$26,000

$48,000

6

$30,000

$55,000

7

$33,000

$62,000

8+

$37,000

$68,000

Page 4

11. Do you or any member of your household currently receive [FILL STATE SNAP NAME]? This program puts
money on an EBT card that you can use to buy food.


d
r
1
0

YES
GO TO INT CHECK #1
NO
DON’T KNOW
GO TO INT CHECK #2
REFUSED

INTERVIEWER CHECK #1
IS QUOTA GROUP D OPEN?
1

YES

0

NO

GO TO “ELIGIBLE” SECTION
GO TO “INTERVIEWER CHECK #2”

FILL FOR QUESTION 11
ROW STATE

FILL STATE SNAP NAME

1

AL, AR, CT, IL,KY, LA, MS

SNAP

2

ND, NE, NM, PA, SC, SD, TX

SNAP

3

FL, KS, MI, OH

Food Assistance Program

4

AZ

Nutrition Assistance

5

CA

CalFresh

6

IN

Food Stamp or SNAP

7

NC

Food and Nutrition Services

8

NJ

NJ SNAP

9

NY

Food Stamps

10

WA

Basic Food

11

WI

FoodShare

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

YES

0

NO

GO TO “ELIGIBLE” SECTION
GO TO “NOT ELIGIBLE” SECTION

NOT ELIGIBLE CONTINUE HERE
Thank you for your time. I’m sorry your household is not eligible for the study.
READ IF NECESSARY: In order to produce a representative sample we only take households with certain characteristics.
Based on your responses you are not eligible at this time.
22. 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
d  DON’T KNOW
r  REFUSED
0

23. WHAT LANGUAGE WAS USED FOR THIS INTERVIEW?


3
4
5
6
1
2

ENGLISH
SPANISH
KOREAN
VIETNAMESE
CHINESE
TRANSLATED BY OTHER HH MEMBER

THANK AGAIN AND TERMINATE. STATUS ON CONTACT SHEET 023.
Page 5

ELIGIBLE CONTINUE HERE
12. Are you the person who does most of the shopping for food in your household?
 YES
0  NO
d  DON’T KNOW
r  REFUSED
1

13. Are you the person who does most of the planning or preparing of meals in your household?
IF RESPONDENT ANSWERS “SOMETIMES” OR “50/50,” ENTER YES.
 YES
 NO
d  DON’T KNOW
r  REFUSED
1

0

GO TO INTERVIEWER CHECK #3

INTERVIEWER CHECK #3:
IS RESPONDENT THE MEAL PLANNER OR FOOD SHOPPER?
YES
NO

1
0

GO TO CONTACT INFORMATION
GO TO Q.14

14. Your household is eligible to take part in the study, but I need to speak with the person who does most of
the shopping for food in your household. What is the name of the person who does most of the shopping for
food?
FIRST NAME

15. Can I speak with [FILL Q.14 NAME]?
 YES
GO TO NEW RESPONDENT INTRO
0  NO
d  DON’T KNOW
GO TO Q.16
r  REFUSED
1

16. What is the best telephone number to reach [FILL Q.14 NAME] at?
(______) - ______ - _______________
Area Code

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

As I mentioned, your household is eligible for the study, but I need to speak with the Food Shopper or Meal
Planner. I’d like to schedule a time to come back.
IF PHONE NUMBER PROVIDED:

I will call [FILL Q.14 NAME] at the phone number you provided to
schedule a time to come back. When is a good time to call?

IF PHONE NUMBER NOT PROVIDED:

When is a good time to come back?

WHEN YOU RETURN TO TALK TO THE RESPONDENT START AT THE NEW RESPONDENT INTRO ON PAGE 7.

Page 6

NEW RESPONDENT INTRO:
Hello. My name is [FILL NAME]. I work for Mathematica Policy Research and we’re conducting a survey for the U.S.
Department of Agriculture. SHOW ID CARD.
We are looking at the foods households get over the course of a week in order to understand where households get food and
how much they pay for food. This information will help the USDA improve its programs and ensure that all residents of the U.S.
have access to a healthy diet at affordable prices.
The addresses we visit are scientifically selected to represent all households in the country. Taking part is completely voluntary.
We are required by law to use your information for statistical research only and to keep it confidential. Your responses will not
have any effect on services you may receive or may apply for in the future.
GO TO CONTACT INFORMATION

CONTACT INFORMATION:
Your household is eligible for this study! In this study, you will be asked to complete one 30-minute interview and one 35-minute
interview, and keep track of foods you get during the week. You will receive a $100 check at the end of the week. You will also
receive up to three (3) $10 gift cards, one for each time you call us to report the foods you get during the week. Other members
of your household can receive gift cards if they report the foods they get during the week.
I’d like to get your contact information before we continue.

17. What is your name?
FIRST NAME

18. What is the best telephone number to reach you at?
(______) - ______ - _______________
Area Code

NO TELEPHONE
DON’T KNOW
REFUSED

0
d
r

SKIP TO Q.20

19. Is there another number where you can be reached?
(______) - ______ - _______________
Area Code

NO TELEPHONE
DON’T KNOW
REFUSED

0
d
r

20. What language would you be most comfortable using for our interviews?
1

ENGLISH
SPANISH
3  KOREAN
2

4

VIETNAMESE

5

OTHER (SPECIFY)

21. 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
2  NO
3

NO

CONTINUE TO INITIAL INTERVIEW AND TRAINING. STATUS ON CONTACT SHEET 021.
NO. SCHEDULE ALTERNATIVE TIME FOR INTITIAL INTERVIEW AND TRAINING. STATUS ON CONTACT
SHEET 021.
REFUSED TO PARTICIPATE. GO TO LAST PAGE (Q.24). STATUS ON CONTACT SHEET 022.

Page 7

REFUSALS
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. I
would like to ask a few questions that will provide us with
information about households that choose not to
participate. This will help us better understand food
choices by all households in this area. 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 household.

24. May I begin?
 YES
0  NO

26. In the past 30 days did you or anyone in your
household get any food from a…
YES

TERMINATE

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

DON’T
KNOW

REF

a. Supermarket

1



0



d



r



b. Small grocery store

1



0



d



r



c. Convenience store

1



0



d



r



d. Dollar store

1



0



d



r



1



0



d



r



1



0



d



r



g. Bakeries

1



0



d



r



h. Meat or fish markets

1



0



d



r



i. Produce store or vegetable
stand

1



0



d



r



j. Pharmacy or drug store

1



0



d



r



k. Food pantry or food bank

1



0



d



r



e. Discount or big box store
(Kmart, Target, or Walmart)

f. Wholesale club

1

NO

(Costco, BJ’s, or Sam’s Club)

______________________________________

27. How many people in your household are…
25a. ASK IF NECESSARY: What type of store is that?
READ CATEGORIES IF NECESSARY
 SUPERMARKET
2  SMALL GROCERY STORE
3  CONVENIENCE STORE

NUM

DON’T
KNOW

REF

Under age…………….…. # _____

d



r



Age 5-9…………………... # _____

d



r



Age 10-13………………... # _____

d



r



Age 14-18………………... # _____

d



r



Over 18 years old………. # _____

d



r



1

(7-11 OR MINIMART)

 DOLLAR STORE
5  DISCOUNT OR BIG BOX STORE
4

(KMART, TARGET, OR WALMART)
6

 WHOLESALE CLUB
(COSTCO, BJ’S OR SAM’S CLUB)

 OTHER
 DON’T KNOW
r  REFUSED

28. How many people over 18 years old in your
household are…

7

NUM

d

DON’T
KNOW

REF

# _____

d



r



Employed part time…….. # _____

d



r



Disabled and unable to
# _____
work…….………………....

d



r



Retired….………………... # _____

d



r



Employed full time…..….

Those are all the questions I have. 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

HOUSEHOLD INCOME SOURCES
(1)   Earnings from work 

(7)    Child support 

(2)   Unemployment compensation 

(8)    Alimony 

(3)   Workers compensation 

(9)    Cash welfare (like TANF/GA) 

(4)   Disability or SSI 

(10)  Investments 

(5)   Social security 

(11)  Other 

(6)   Pensions and retirement 

TOTAL HOUSEHOLD INCOME

HH Size = 1

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $210 

$0  ‐  $900 

$0  ‐  $11,000 

(B) 

$210  ‐  $390 

$900  ‐  $1,700 

$11,000  ‐  $20,000 

(C) 

$390+ 

$1,700+ 

$20,000+ 

PER WEEK 

TOTAL HOUSEHOLD INCOME

HH Size = 2

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $280 

$0  ‐  $1,200 

$0  ‐  $15,000 

(B) 

$280  ‐  $520 

(C) 

$520+ 

PER WEEK 

$1,200  ‐  $2,200  $15,000  ‐  $27,000 
$2,200+ 

$27,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 3

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $350 

$0  ‐  $1,500 

$0  ‐  $18,000 

(B) 

$350  ‐  $650 

(C) 

$650+ 

PER WEEK 

$1,500  ‐  $2,800  $18,000  ‐  $34,000 
$2,800+ 

$34,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 4

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $420 

$0  ‐  $1,800 

$0  ‐  $22,000 

(B) 

$420  ‐  $780 

(C) 

$780+ 

PER WEEK 

$1,800  ‐  $3,400  $22,000  ‐  $41,000 
$3,400+ 

$41,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 5

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $500 

$0  ‐  $2,100 

$0  ‐  $26,000 

(B) 

$500  ‐  $920 

(C) 

$920+ 

PER WEEK 

$2,100  ‐  $4,000  $26,000  ‐  $48,000 
$4,000+ 

$48,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 6

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $570 

$0  ‐  $2,500 

$0  ‐  $30,000 

(B) 
(C) 

PER WEEK 

$570  ‐  $1,050  $2,500  ‐  $4,600  $30,000  ‐  $55,000 
$1,050+ 

$4,600+ 

$55,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 7

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $640 

$0  ‐  $2,800 

$0  ‐  $33,000 

(B) 
(C) 

PER WEEK 

$640  ‐  $1,180  $2,800  ‐  $5,100  $33,000  ‐  $62,000 
$1,180+ 

$5,100+ 

$62,000+ 

TOTAL HOUSEHOLD INCOME

HH Size = 8+

(INGRESO TOTAL DEL HOGAR)

GROUP 
(Grupo) 

(por semana) 

PER MONTH 
(por mes) 

PER YEAR 
(por año) 

(A) 

$0  ‐  $710 

$0  ‐  $3,100 

$0  ‐  $37,000 

(B) 
(C) 

PER WEEK 

$710  ‐  $1,320  $3,100  ‐  $5,700  $37,000  ‐  $68,000 
$1,320+ 

$5,700+ 

$68,000+