National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX R
RESPONDENT FEEDBACK FORM

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OMB: xxxx-xxxx
Expiration Date: 12/31/2012

National Food Study
Mathematica Policy Research – Respondent Feedback Form
Please tell us about your experience with the National Food Study. Your honest feedback is important to us and will help
us improve the study for others.
1. How often did you complete the Meals and Snacks form? (Check one)
1

 Everyday

2

 More than once but not every day

3

 Once before the end of the week

4

 Once at the end of the week

5

 Did not complete at all

On a scale from 1 to 5, where 1 is “very easy” and a 5 is “very difficult”, please tell us
2.

How easy or difficult was it for you to get other household members to take part in the study? (Check one)
Very Easy
1

3.



Easy
2



Neither easy nor
difficult
3



Difficult
4



Very difficult
5



Not applicable
6



How easy or difficult was it to keep track of the foods you got? (Check one)
Very Easy
1



Easy
2



Neither easy
nor difficult
3



Difficult
4



Very difficult
5



4. During the past week, did you (or other household members) change the way you got food because you were
taking part in this study? (Check all that apply)
1

 Ate out more often

2

 Ate out less often

3

 Did more food shopping

4

 Did less food shopping

5

 Bought a specific item(s) just to be able to scan it

6

 Avoided specific items so you wouldn’t have to scan them

7

 Other changes – please specify: ________________________________

8

 No, did not change

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 3 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.