National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX H
INITIAL HOUSEHOLD INTERVIEW AND HAND CARDS

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

Initial Interview
PROGRAMMER NOTES:
•

THROUGHOUT, FOR QUESTIONS THAT HAVE A PARENTHESES WITH SINGULAR AND PLURAL MODES OF ASKING THE
QUESTION: IF HOUSEHOLD SIZE = 1 USE THE FIRST PART OF THE PARENTHESES; IF HOUSEHOLD SIZE >1 USE THE
SECOND PART OF THE PARENTHESES

•

WHEN A NAME IS REQUESTED (FIRST, LAST) THE FIELD INTERVIEWER SHOULD BE ABLE TO LEAVE EITHER FIELD BLANK
IF THE RESPONDENT REFUSES TO PROVIDE EITHER PORTION OF THE NAME FIELD.

•

IF Q2 = C OR ANYTIME THE RESPONDENT BREAKS OFF THE INTERVIEW (REFUSES TO CONTINUE) DISPLAY THE
FOLLOWING NOTE:

I respect your decision not to take part in this study. For every household that chooses not to participate, we try to
ask a few short questions that enable us to better understand food choices by comparing households that
participate to households not participating. I remind you that we are required by law to use your information for
statistical research only and to keep it confidential. [IF RESPONDENT AGREES, FILL OUT THE BACK PAGE
ON THE SCREENER].

INTRODUCTION
ALL
Q1a.

DID THE HOUSEHOLD PROVIDE CONSENT FOR USE OF ADMINISTRATIVE DATA BY INITIALING THE SECOND PAGE
OF THE CONSENT FORM?
(1) YES
(0) NO

ALL
Q2. As I said earlier, taking part in this study is completely 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 members of your household. You 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 on the
brochure.
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. Some of these questions will help me determine how many food books to give you for the study week,
and some of the questions will be used by researchers to help them understand how households like yours acquire food.
These questions will take about 30 minutes to answer.
May I begin?
(A) YES, CONTINUE → CONTINUE TO
(B) NO → GO TO APPOINTMENT SCREEN
(C) DECLINES TO TAKE PART → TERMINATE STATUS: 220 (REFUSAL)
DO NOT ALLOW DK / REF IN Q2 RESPONSE OPTIONS FOR Q2.

1

SECTION A.

HOUSEHOLD ROSTER

We will begin the interview with questions about who lives here. I need to make a list of all the people who
are living or staying here at this address over the next week. Be sure to include: People who stay here only some of the
time; non-relatives who live here; and any babies and small children. Please mention someone even if you're not sure
they should be included. I understand that you may have already provided some of this information, but I need to read
the whole series of questions.
ALL. BEGIN LOOP. FILL ACROSS THEN DOWN. FILL FIRST NAME, SEX, RELATIONSHIP TO R, HOUSEHOLD MEMBER ABSENT AT
TIME OF SURVEY, NON-HOUSEHOLD MEMBER, STAYING IN SAMPLE UNIT AT TIME OF SURVEY. END LOOP.
A1. Let's start with you. What is your name?
INTERVIEWER NOTE: IF RESPONDENT REFUSES NAME, PROBE FOR INITIALS OR MEANINGFUL NICKNAME, EXPLAIN
THAT THIS IS THE NAME YOU WILL USE LATER IN THIS INTERVIEW, AS WELL AS IN OTHER INTERVIEWS LATER THIS
WEEK TO TELL HOUSEHOLD MEMBERS APART. IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES
(TWO FIELDS), ONE OF THE FIELDS CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
ALL
A1_MEMCK2.

Does anyone else live or stay here?
(1) YES
(0) NO: NO ONE ELSE LIVES / STAYS HERE BESIDES ME – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

CAPI: THE TOTAL HH ROSTER SIZE (ACROSS ALL PORTIONS OF SECTION A) CAPS AT 20 NAMES TOTAL.
A1_MEMCK2 = 1
A1_MEM1.
Please give me the names of everyone else who lives or stays here most of the time.
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), ONE OF THE FIELDS
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(00) → SKIP TO A2
(r) REFUSED → SKIP TO A2
(d) DON’T KNOW → SKIP TO A2
A1_MEMCK2 = 1
A1_MEMCK3.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

2

A1_MEMCK3 = 1
A1_MEM2.
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), ONE OF THE FIELDS
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK3 = 1
A1_MEMCK4.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

A1_MEMCK4 = 1
A1_MEM3:
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), THE OTHER FIELD
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK4 = 1
A1_MEMCK5.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

A1_MEMCK5 = 1
A1_MEM4:
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), THE OTHER FIELD
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK5 = 1
A1_MEMCK6.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

3

A1_MEMCK6 = 1
A1_MEM5:
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), THE OTHER FIELD
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK6= 1
A1_MEMCK7.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

A1_MEMCK7 = 1
A1_MEM6:
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), THE OTHER FIELD
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK7 = 1
A1_MEMCK8.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

A1_MEMCK8 = 1
A1_MEM7:
What is that person’s name?
INTERVIEWER NOTE: IF RESPONDENT WILL NOT PROVIDE BOTH FIRST AND LAST NAMES (TWO FIELDS), THE OTHER FIELD
CAN BE LEFT BLANK.
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A1_MEMCK8 = 1
A1_MEMCK9.

Anyone else?
(1) YES
(0) NO – SKIP TO A2
(r) REFUSED – SKIP TO A2
(d) DON’T KNOW – SKIP TO A2

4

CONTINUE THROUGH A MAXIMUM OF 20 NAMES
CAPI: FOR THIS STUDY, WE ARE CAPPING HH SIZE AT 20 TOTAL PERSONS. THEREFORE, THIS SERIES ENDS AT MEM19, AS
MEMBER 1 = RESPONDENT (IDENTIFIED IN A1).
ALL
A2. I need to be sure I'm including the correct people in this survey. You have mentioned [CAPI: FILL ALL NAMES FROM A1
THROUGH A1_MEM19]. Is this the address where [you/you and they] live and sleep most of the time?
(1) YES  SKIP TO A3
(0) NO
(r) REFUSED  SKIP TO A3
(d) DON’T KNOW  SKIP TO A3
IF A2=0. FILL [NAMES] FROM A1 (HOUSEHOLD ROSTER)
A2a. Who doesn't live or sleep here most of the time? (CHECK ALL THAT APPLY)
PROBE: Anyone else?
CAPI: PRESENT ALL NAMES LISTED IN A1 THROUGH A1_MEM19
(r) REFUSED
(d) DON’T KNOW
ASK A2b-A2d FOR EACH NAME SELECTED IN A2a.
IF NAME IN A2a = CHECKED, FILL NAME FROM A2a IN A2b
A2b. Is there another place where [NAME FROM A2a] lives and sleeps most of the time?
(1) YES
(0) NO  SKIP TO NEXT PERSON OR IF NO OTHERS, CONTINUE TO A3
(r) REFUSED  SKIP TO NEXT PERSON OR IF NO OTHERS, CONTINUE TO A3
(d) DON’T KNOW  SKIP TO NEXT PERSON OR IF NO OTHERS, CONTINUE TO A3
A2b=1
A2c. I am going to read a list of reasons why people may have another place where they live or sleep most of the time.
Please tell me which of these is the main reason for [NAME FROM A2a] . . .
(1) A college student who usually lives away at school? (IF NEEDED: COLLEGE STUDENT WITH ON-CAMPUS OR
OFF-CAMPUS HOUSING WHO IS HERE TEMPORARILY)
(2) A boarding school student who usually lives away at school but is home for break or vacation
(3) A boarding school student who usually lives away at school during the week but is here on weekends
(4) In the Armed Forces, stationed locally
(5) In the Armed Forces and is temporarily here on leave, but stationed elsewhere
(6) In an institution such as a home for the aged, mental hospital, or prison?
(7) Temporarily absent on vacation or in hospital?
(8) Temporarily on the road for a job or work
(9) Absent in connection with a job – lives both here and elsewhere, but does not stay here often
(10) Has another home but sleeps here more often
(11) Has another home and sleeps in other home more often
(r) REFUSED
(d) DON’T KNOW
CAPI: RESPONSE OPTIONS FOR A2c 1-9, 11, d, r SKIP TO A2d FROM HERE.

5

A2c = 10
A2c1.
Does [he / she ] get mail here?
(1) YES
(2) NO
(r) REFUSED
(d) DON’T KNOW
A2c=1, 2, 5, 6, 9, 11 OR A2c1=2, d, r
A2d. INTERVIEWER ENTER:
(1) PRESENT FOR THE NEXT WEEK
(2) NOT PRESENT FOR THE NEXT WEEK
[CAPI CODE RESPONSE 2: IF FLAG 1=OFF THEN FLAG 2=OFF]
CAPI: CREATE TWO FLAGS AND TURN ON BY DEFAULT WHEN A NAME IS ENTERED IN THE ROSTER (SLOTS 1-20).
SPECIFICATIONS ARE AS FOLLOWS:
FLAG DESCRIPTION
If FLAG1 is on:
Member gets asked Income in Final Interview
IF FLAG2 IS ON:
Member gets asked all demographics (Initial
Interview) and is designated to receive a Food
Booklet

TURN FLAG OFF IF
If NOT HH MEMBER

Condition =
A2c=1, 2, 5, 6, 9, 11 OR A2c1=2, d, r

If FLAG1=OFF
[NOT HH MEMBER] AND
NOT PRESENT NEXT WEEK.

If FLAG1 = off AND (A2d=2)

IF FLAG1=OFF, DO NOT INCLUDE NAME FOR CAPI #2 INCOME AND EXPENSE QUESTIONS
IF FLAG2=OFF, DO NOT INCLUDE NAME FOR ANY SUBSEQUENT QUESTIONS IN CAPI #1 AND CAPI #2
PROGRAMMER LOOP: REPEAT A2b-A2d FOR EACH PERSON IDENTIFIED IN A2a.
ALL
A3. Sometimes we miss people when it's not totally clear where they live. Just to make sure, have I missed anyone who is
staying here until they find a place to live?
(1) YES
(0) NO 
SKIP TO A3b1
(r) REFUSED 
SKIP TO A3b1
(99) DON’T KNOW  SKIP TO A3b1
IF A3=1 BEGIN LOOP UNTIL NO OTHER NAMES TO ADD.
CAPI: THE TOTAL HH ROSTER SIZE (ACROSS ALL PORTIONS OF SECTION A) CAPS AT 12 NAMES TOTAL.
A3a. Who is that?
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
CAPI: ADD NAME ON ROSTER (UP TO 20 TOTAL IN HH) AND SET FLAG 1 = OFF, FLAG 2=ON FOR THESE NAMES
IDENTIFIED IN A3a.

6

ALL
A3b1.
Any lodgers, boarders or persons you employ who live here?
CAPI: THE DATA CAPTURED IN A3b1-4 DO NOT FACTOR INTO HH ROSTER OR HH SIZE.
(1) YES
(0) NO  SKIP TO A3C
(r) REFUSED  SKIP TO A3C
(d) DON’T KNOW  SKIP TO A3C
IF A3b1=1
A3b2.
How many lodgers live here?
|___|__ |CAPI: ALLOWABLE RANGE = 00-20
(r) REFUSED
(d) DON’T KNOW
IF A3b1=1
A3b3.
How many boarders live here?
|___|__ |CAPI: ALLOWABLE RANGE = 00-20
(r) REFUSED
(d) DON’T KNOW
IF A3b1=1
A3b4.
How many persons you employ who live here?
|___|__ |CAPI: ALLOWABLE RANGE = 00-20
(r) REFUSED
(d) DON’T KNOW
ALL
A3c. Anyone who may have another place to live, but who stays here often or has some space or a room here?
(1) YES
(0) NO  SKIP TO A4
(r) REFUSED  SKIP TO A4
(d) DON’T KNOW  SKIP TO A4
A3c=1
A3c1.

How many people may have another place to live, but stay here often or have some space or a room
here?
|___|__ |CAPI: ALLOWABLE RANGE = 1-20
(r) REFUSED  SKIP TO A4
(d) DON’T KNOW  SKIP TO A4

A3c1=>1
A3c2.
How many of those people will be staying here during the next week?
|___|__ |CAPI: ALLOWABLE RANGE = 00-20
(r) REFUSED
(d) DON’T KNOW
CAPI: THE TOTAL HH ROSTER SIZE (ACROSS ALL PORTIONS OF SECTION A) CAPS AT 20 NAMES TOTAL.
7

CAPI: REPEAT A3c3 FOR TOTAL N IN A3c2 THEN SKIP TO A4
A3c2> 01 AND HH ROSTER <20 PEOPLE COLLECTED THUS FAR
A3c3.
Please tell me the name of each person who may have another place to live, but stays here often or
has some space or a room here and will be here for the next week.
SPECIFY FIRST NAME: ______ (string 20 char)
SPECIFY LAST NAME: __________ (string 30 char) →SKIP TO NEXT PERSON UNTIL LOOP COMPLETE,
THEN SKIP TO A4
(r) REFUSED →SKIP TO NEXT PERSON UNTIL LOOP COMPLETE, THEN SKIP TO A4
(d) DON’T KNOW →SKIP TO NEXT PERSON UNTIL LOOP COMPLETE, THEN SKIP TO A4
CATI: FOR EACH PERSON NAMED IN A3c3, TURN OFF FLAG 1, TURN ON FLAG 2
According to the rules of this survey, [READ ALL NAMES FROM ROSTER] will be included in this interview.
INTERVIEWER NOTE: NO ADDITIONAL HH MEMBERS MAY BE ADDED TO THE SURVEY FROM THIS POINT FORWARD. DO
NOT GO BACK TO SECTION A TO ADD MORE MEMBERS. CONTINUE INTERVIEW WITH PERSONS LISTED BELOW.
CAPI: INSERT LIST OF NAMES GATHERED FROM HH ROSTER (FLAG2=ON) IN THIS FIELD BELOW.
CAPI: NO ADDITIONAL HH MEMBERS’ NAMES CAN BE ADDED TO THE ROSTER FROM THIS JUNCTURE.
HH DEMOGRAPHICS WILL BE CAPTURED FOR THE FIRST 20 NAMES IN THE HH ROSTER WHERE FLAG 2=ON.
COMPLETE EACH QUESTION FOR ALL MEMBERS OF HOUSEHOLD IF NOT ALREADY OFFERED THEN MOVE TO NEXT
QUESTION. FILL [NAME] FROM ROSTER AND LOOP UNTIL ALL NAMES ARE COMPLETED.
ALL WHERE FLAG 2 = ON
A4. [ASK IF NOT APPARENT] Is [FILL ROSTER NAME] male or female?
(1) Male
(2) Female
(r) REFUSED
(d) DON’T KNOW
ALL. FILL [NAME] FROM ROSTER AND LOOP UNTIL ALL NAMES ARE COMPLETED.
DO NOT ALLOW A (d) RESPONSE TO THIS ITEM.
A5. What is [NAME’s] relationship to you?
(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
(r) REFUSED

CAPI: AT THE END OF LIST OF HH MEMBERS, PLACE SOFT EDIT CONFIRMATION SCREEN WHICH IDENTIFIES EACH HH
MEMBER NAME AND THE TEXT CORRESPONDING TO THE RELATIONSHIP CODE SELECTED FROM LIST BELOW. TEXT ON EDIT
CHECK SHOULD READ:
Just to confirm – I am going to read each person’s name and their relationship to you to make sure I have this listed
correctly. If I have marked anything incorrectly, please let me know.

8

ALL WHERE FLAG 2=ON. FILL [NAME] FROM ROSTER AND LOOP UNTIL ALL NAMES ARE COMPLETED.
A6. How old (are you /is [NAME])?
|__|__|__| ENTER AGE IN YEARS (RANGE OF 0-120,d,r) →IF UNDER 18, CONTINUE TO A6a ELSE TO A7
(r) REFUSED → SKIP TO A6b
(d) DON’T KNOW → SKIP TO A6b
IF A6 < 18, FILL NAME FROM ROSTER.
A6a. IF UNDER 18 – What is (your / FILL NAME’s) month and year of birth?
|__|__| MONTH ( ALLOWABLE VALUE RANGE 01-12, d, r)
|__|__|__|__| YEAR (ALLOWABLE VALUE RANGE 1993-2012, d, r)
CAPI: INSERT SOFT EDIT CHECK HERE IF CALCULATION OF AGE BASED ON YEAR RESPONSE IN A6A IS NOT EQUAL TO
NUMERIC VALUE OF AGE IN YEARS (LISTED IN A6). TEXT WILL READ: You said [NAME] is [FILL RESPONSE TO A6] and was
born in [FILL YEAR GIVEN IN A6a], is that correct?
CAPI CHECK: NEED AT LEAST ONE PERSON IN THE HOUSEHOLD ROSTER AGE 18 YEARS OR OLDER, ELSE
TERMINATE. IF NO ONE AGE 18 AND OLDER, INTERVIEWER READ: I’m sorry, your household is not eligible for the study.
We need to speak with someone age 18 or older.
CAPI: STATUS CODE FOR CASES TERMINATING HERE: INELIGIBLE –#023
CAPI: A7 THROUGH A13 = DEMOGRAPHIC SERIES –ASKED OF ALL HH MEMBERS WHERE FLAG 2=ON.
ALL. LOOP THROUGH A7 –A8 FOR EACH NAME FROM HOUSEHOLD ROSTER, THEN PROCEED TO A9.
CAPI: THE FIRST TIME YOU DO THE LOOP, ALWAYS FILL WITH FIRST PORTION OF PARENTHESIS. IF NEEDED, FOR ALL
SUBSEQUENT LOOPS, FILL NAME / USE SECOND PORTION OF TEXT IN THE PARENTHESIS.
ALL WHERE FLAG 2 = ON
A7. (Are you/Is [FILL NAME]) Spanish, Hispanic, or Latino?
READ IF NECESSARY: such as Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or some other Spanish,
Hispanic, or Latino group.
(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
(r) REFUSED
(d) DON’T KNOW
ALL WHERE FLAG 2 = ON
A8. I’m going to show you a list of five race categories. Please choose one or more races that you consider (yourself/[FILL
NAME]) to be. INTERVIEWER: SHOW HAND CARD, IF RESPONDENT WOULD LIKE IT.
(1) White
(2) Black or African American
(3) American Indian or Alaska Native
(4) Asian
(5) Native Hawaiian or Other Pacific Islander
(6) OTHER – SPECIFY: ___________________
(r) REFUSED
(d) DON’T KNOW
If A8=4:
9

A8a. Which of the following Asian groups ([IF HH Size =1 FILL: are you]/[IF A4=1 FILL: is he] / [IF A4=2 FILL: is she)?
(1) Asian Indian
(2) Chinese
(3) Filipino
(4) Japanese
(5) Korean
(6) Vietnamese
(7) OTHER - DO NOT READ
(r) REFUSED
(d) DON’T KNOW
ALL WHERE FLAG 2 = ON
A9. We’d like to know if you might need extra help with this survey because of physical, mental, or emotional conditions.
Because of a disability, do you have difficulty using the telephone?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL WHERE FLAG 2 = ON
A9a. Because of a disability, do you have difficulty writing with a pen or pencil?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL WHERE FLAG 2 = ON
A9b. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or
making decisions?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
A9c. Do you have vision or other problems that make it difficult to read?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
CAPI: IF ITEMS A9a, A9b, OR A9c = 1, SEND THIS DATA THROUGH THE TRANSFER PROCESS TO UPLOAD INTO THE WEBBASED SYSTEM.

10

IF A9, A9a, A9b, or A9c = 1
A9d. This survey requires you to track (your/your household’s) food acquisitions by completing hand-written forms,
scanning barcodes on the food items you get, and calling our phone center to report your acquisitions. Will you be able to
do these things on your own or is there someone else who can help you complete the survey requirements? PROBE: This
might be someone who lives with you, a friend, or someone like a social worker or caseworker.
(1) YES - ON THEIR OWN
(2) NO – SOMEONE CAN HELP
(3) NO – NO ONE CAN HELP
(r) REFUSED
(d) DON’T KNOW

A9d=2
A9e1. What is the name of the person who can help?
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A9e1^=R,D
CAPI DISPLAY THE FOLLOWING: I would like to schedule a time to come back to discuss the study with you and [FIRST NAME
A9e1]. Is there a good time for me to come back? INTERVIEWER NOTE: WRITE THE APPOINTMENT TIME ON THE CONTACT
SHEET.

A9d=3,R,D
A9e2. I’m sorry but our study rules say that we need to find someone else who can help complete the survey requirements.
If you can think of someone who can help, I can come back to discuss the study with you and that person. Otherwise you
cannot participate at this time.
(1) CAN IDENTIFY SOMEONE TO HELP
(2) CANNOT IDENTIFY SOMEONE TO HELP
(r) REFUSED
(d) DON’T KNOW
A9e2=1
A9e3. What is the name of the person who can help?
SPECIFY FIRST NAME: _____________ (string 20 char)
SPECIFY LAST NAME: _____________ (string 30 char)
(r) REFUSED
(d) DON’T KNOW
A9e2=2,R,D
CAPI DISPLAY THE FOLLOWING: Thank you very much for your time and your willingness to participate in the study, but you
cannot participate at this time. INTERVIEWER: LEAVE YOUR CONTACT INFORMATION WITH THE RESPONDENT IN CASE HE
OR SHE HAS QUESTIONS OR IDENTIFIES A PERSON AFTER YOU LEAVE THAT CAN HELP WITH THE STUDY. CAPI – EXIT AND
CODE AS PHYSICAL/COGNITIVE BARRIER (410).

11

IF AGE FROM ROSTER > 16. FILL [NAME] FROM ROSTER.
CAPI: ASK A10 -A12 FOR EACH MEMBER OF HOUSEHOLD, AGE 16+. (WHERE A6>16 OR d, r); WHERE FLAG 2 = ON
A10. What is the highest level of school (you/FILL NAME) completed or the highest degree (you/FILL NAME) received?
(How about [FILL NAME])? INTERVIEWER: SHOW HAND CARD, IF NEEDED.
(11) LESS THAN 1ST GRADE
(12) 1ST, 2ND, 3RD OR 4TH GRADE
(13) 5TH OR 6TH GRADE
(14) 7TH OR 8TH GRADE
(15) 9TH GRADE
(16) 10TH GRADE
(17) 11TH GRADE
(18) 12TH GRADE, NO DIPLOMA
(19) HIGH SCHOOL GRADUATE WITH DIPLOMA
(20) HIGH SCHOOL GRADUATE WITH GED OR EQUIVALENT
(21) 1 OR MORE YEARS OF COLLEGE, NO DEGREE (REGULAR JR.COLL./COLL./UNIV.)
(22) ASSOCIATE (2-YR) COLLEGE DEGREE
(23) BACHELOR'S DEGREE (E.G., BA, AB, BS)
(24) MASTER'S OR HIGHER DEGREE (E.G., MA, MS, MENG, MED, MSW, MBA, JD, MD, PH.D, ED.D)
(r) REFUSED
(d) DON’T KNOW
ALL IF AGE (A6) is > 16 or d, r. FOR ALL WHERE FLAG 2 = ON - FILL [NAME] FROM ROSTER.
LOOP A11-A11b1 UNTIL ALL NAMES FROM HH ROSTER WHERE A6 > 16 HAVE BEEN FILLED.
A11. (Are you/Is [NAME]) currently married, widowed, divorced, separated or (have you/[IF A4=1 FILL: has he] or [IF A4=2
FILL: has she]) never married?
(1) MARRIED
(2) WIDOWED
(3) DIVORCED
(4) SEPARATED
(5) NEVER MARRIED
(r) REFUSED
(d) DON’T KNOW
A11a.

FOR NEXT PERSON ON ROSTER, How about [NAME]? Is [NAME] currently married, widowed, divorced,
separated or has ([IF A4=1 FILL: he] / [ IF A4=2 FILL: she]) never married?
(1) MARRIED
(2) WIDOWED
(3) DIVORCED
(4) SEPARATED

(5) NEVER MARRIED
(r) REFUSED
(d) DON’T KNOW

A11=1
A11b. IF MARRIED, ASK IF NECESSARY: Is [NAME’S] spouse a member of this household?
(1) YES
(0) NO – SKIP TO A12
(r) REFUSED – SKIP TO A12
(d) DON’T KNOW – SKIP TO A12

12

A11B=1
A11b1.

CAPI – PRESENT LIST OF PERSON CODES AND NAMES FOR ALL ADULT HH MEMBERS IN ROSTER.
MEMBERS IDENTIFIED WITH OTHER MEMBERS AT PREVIOUS RESPONSES DO NOT NEED TO BE LISTED.
INTERVIEWER: SELECT SPOUSE FROM ALL ADULT HOUSEHOLD MEMBERS.
|___|___| SELECT CODE (01-20)
(r) REFUSED

FOR EACH ITEM IN THIS SERIES - FILL [NAME] FROM ROSTER. LOOP THROUGH A12, A12a, A12b, A12c THEN LOOP TO NEXT
NAME UNTIL ALL NAMES FROM ROSTER AGE > 16 HAVE BEEN FILLED.
ALL HH MEMBERS WHERE AGE (A6)= > 16, or d, r. WHERE FLAG 2 = ON
A12. The next questions are about (your/[NAME’s]) current job or business. Which of the following (were you/was [NAME])
doing last week . . .
(1)
(2)
(3)
(4)
(r)
(d)

working at a job or business  SKIP TO A12c
with a job or business but not at work  SKIP TO A12c
looking for work, or  GO TO A12a
not working at a job or business?  SKIP TO A12b
REFUSED
DON'T KNOW

A12=3, r, d
A12a. Did (you/[NAME]) do any work at a job or business at all last week (include unpaid work in a family farm or
business)?
(1) YES SKIP TO A12c
(0) NO GO TO A12b
(r) REFUSED  SKIP TO NEXT PERSON OR A12b IF LAST PERSON IN LOOP
(d) DON'T KNOW  SKIP TO NEXT PERSON OR A12b IF LAST PERSON IN LOOP
A12=4 OR A12a=0
A12b. What is the main reason (you/[FILL NAME]) did not work last week?
(1)
(2)
(3)
(4)
(5)
(6)

TAKING CARE OF HOUSE OR FAMILY  SKIP TO A13
GOING TO SCHOOL  SKIP TO A13
RETIRED  SKIP TO A13
UNABLE TO WORK FOR HEALTH REASONS  SKIP TO A13
DISABLED  SKIP TO A13
ON LAYOFF / UNEMPLOYED  SKIP TO A13

(7) ON VACATION
(8) ON STRIKE
(9) OTHER  SKIP TO A13
(r) REFUSED  SKIP TO A13
(d) DON'T KNOW  SKIP TO A13

A12=1, 2 OR A12b=7, 8
A12c. When at work, where (do you/does NAME) usually get food (for example, for lunch or dinner)?
(1)
(2)
(3)
(4)
(5)
(r)
(d)

WORKPLACE - PURCHASE
WORKPLACE– FREE
PURCHASE FROM STORE OR RESTAURANT
BRING FOOD FROM HOME
DO NOT EAT FOOD AT WORK
REFUSED
DON’T KNOW

13

ALL WHERE FLAG 2 = ON
A13. Is anyone in the household a migrant or seasonal farm worker?
(1) YES
(0) NO
(r) REFUSED
(d) DON'T KNOW
ALL WHERE FLAG 2 = ON
A14. (Are you/Is anyone in the household) self-employed?
(1) YES
(0) NO
(r) REFUSED
(d) DON'T KNOW

A14=1
A15. (Are you/Is anyone in the household) self-employed in a business that involves food preparation?
(1) YES
(0) NO
(r) REFUSED
(d) DON'T KNOW

SECTION B.
ALL
Q1_1

PROGRAM PARTICIPATION

[Do you / Does anyone in your household receive benefits from the [FILL FOR SNAP PROGRAM] program? This
program used to be called food stamps. It puts money on an [SNAP EBT CARD] card that you can use to buy food.
(1) YES
(0) NO  B3
(r) REFUSED  B3
(d) DON'T KNOW  B3

IF Q1_1=1
B1. On what date did ([IF HH size =1 FILL: you] /[ IF HH size >1 FILL: your household]) last receive [FILL FOR SNAP
PROGRAM] benefits?
CAPI: SEPARATE FIELDS FOR MONTH, DAY AND YEAR, ALLOW ENTRY OF R AND DK IN FIELDS.
|___|___| MONTH
(01-12,d,r)

|___|___| |___|___|
DAY
YEAR
(01-31,d,r)
(01-12, d,r)

IF Q1_1=1
B2. How many dollars were put on (([IF HH size=1 FILL: your] / /[ IF HH size>1 FILL: your household’s]) (SNAP EBT CARD)
card last month from the [FILL FOR SNAP PROGRAM] program?
$ |___|___||___|___|.|___|___| (RANGE 1.00-9999.00, d,r)

14

IF B2>0
B2a. Is that the amount usually added each month, more than the usual amount, or less than the usual amount?
(1) The usual amount  B4
(2) More than the usual amount  B4
(3) Less than the usual amount  B4
(r) Refused  B4
(d) Don’t know  B4

IF Q1_1=0
B3. Have ([IF HH size=1 FILL: you], [IF HH size>1 FILL: anyone in your household]) ever received benefits from the [FILL FOR
SNAP PROGRAM] program?
(1)
(0)
(r)
(d)

YES
NO SKIP TO B4
REFUSED SKIP TO B4
DON’T KNOW SKIP TO B4

IF B3=1
B3a. Did (you/anyone in your household) receive [FILL FOR SNAP PROGRAM] benefits in the last 12 months?
(1)
(0)
(r)
(d)

YES
NO SKIP TO B4
REFUSED SKIP TO B4
DON’T KNOW SKIP TO B4

IF B3a=1
B3b. On what date did (you/your household) last receive [FILL FOR SNAP PROGRAM] benefits?
|___|___| - |___|___| - |___|___|
MONTH
DAY
YEAR
(01-12, D, R) (01-31, D, R) (10-12, D, R)
B3c. How many dollars were put on your [SNAP EBT CARD] card at that time?
$ |___|___||___|___|.|___|___| (RANGE 1.00-9999.00, d,r)
CAPI: WE WILL PROVIDE A LIST OF PSUS WHERE FDPIR OPERATES; SKIP TO B4a FOR ALL OTHER PSUS.
B4. Is anyone in your household now receiving benefits from the Food Distribution Program on Indian Reservations
(FDPIR)?
(1)
(0)
(r)
(d)

YES
NO
REFUSED
DON’T KNOW

15

CAPI: WE WILL PROVIDE A LIST OF PSUS WHERE CSFP OPERATES: SKIP TO B5 FOR ALL OTHER PSUS.
B4a. Is anyone in your household now receiving USDA foods from [LOCAL PROGRAM OR DISTRIBUTION SITE]?
(1)
(0)
(r)
(d)

YES
NO
REFUSED
DON’T KNOW

SCHOOL MEALS PROGRAMS
ASK THIS SECTION FOR EACH HOUSEHOLD MEMBER BETWEEN THE AGES OF 4 AND 15 AND PERSONS AGE (HH INTERVIEW 1
ITEM A6) = > 16 or d, r WITH RESPONSE TO HH INTERVIEW 1 ITEM A10 (EDUCATION) <19 (LESS THAN HIGH SCHOOL
GRADUATE). ASK EACH QUESTION (AND FOLLOW-UP, IF APPLICABLE) FOR EVERY NAME, THEN MOVE TO NEXT QUESTION.
B5. ([IF HH size=1 FILL: Are you] / [ IF HH size>1 FILL: is [FILL NAME]]) currently attending a kindergarten, grade school,
junior or high school? (How about/[FILL NAME]?
CAPI: IF AGE ≥ 16 YEARS (AT A6) AND A10 IS <19 OR d, r (LESS THAN HIGH SCHOOL GRADUATE), SUBSTITUTE ORIGINAL TEXT
FOR B5 WITH: ([IF HH size=1 FILL: Are you] / [ IF HH size>1 FILL: is [FILL NAME]) currently attending school?
(0)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(r)
(d)

NO  GO TO B5a
KINDERGARTEN – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
ELEMENTARY SCHOOL – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
PRIMARY SCHOOL – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
MIDDLE SCHOOL – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
JUNIOR HIGH – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
HIGH SCHOOL – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
SOME OTHER SCHOOL (COLLEGE, TECHNICAL SCHOOL, ETC.)
REFUSED – ASK OF NEXT AGE APPLICABLE HH MEMBER, ELSE SKIP TO B6
DON’T KNOW – ASK OF NEXT AGE APPLICABLE HH MEMBER ELSE, SKIP TO B6

If B5=0
B5a. IF B5=0: What is the reason (you/FILL NAME) is not currently attending school?
(1) SCHOOL BREAK
(2) SUMMER VACATION
(3) HOME SCHOOLED
(4) DROPPED OUT
(5) DISABLED
(6) NOT OLD ENOUGH
(7) OTHER ______________________
(r) REFUSED
(d) DON’T KNOW
IF B5=1, 2, 3, 4, 5, 6
B5b. [Are you/is NAME] attending a public school, private school, or charter school?
(1) Public school
(2) Private school
(3) Charter school
(4) Other school type
(r) Refused
(d) Don’t know

16

IF B5b= 2, 3, 4
B5c. What is the name of the school [you/NAME] is attending?
SPECIFY: _______________________ (STRING 100)
(r)
(d)

REFUSED
DON’T KNOW

IF B5a >2 OR d, r REMOVE FROM LOOP OF THOSE TO ASK QUESTIONS B6-B11
CAPI: LOOP THROUGH B6 AND B6a FOR EACH NAME THEN MOVE TO B7.
B6. Is [FILL NAME’s] school in session now through [FILL TODAY + 10 DAYS], or is it on break or vacation? (How about [FILL
NAME’s] school?
(1)
(2)
(3)
(r)
(d)

IN SESSION  SKIP TO B7
SUMMER BREAK
OTHER BREAK OR VACATION
REFUSED  SKIP TO B7
DON’T KNOW  SKIP TO B7

B6=2, 3
B6a. What are the first and last days of the school break or vacation?
|___|___| |___|___| 1ST VACATION DAY
MONTH
DAY
(01-12, d, r)
(01-31, d, r)
|___|___| - |___|___| LAST VACATION DAY
MONTH
DAY
(01-12, d, r)
(01-31, d, r)
FOR B7 and B8, IF CHILD IS ON SUMMER BREAK (B5a=2), REPLACE “Does” with “Last year, did” [FILL NAME. LOOP THROUGH
B7, B7a, AND B7b FOR EACH NAME, THEN GO TO B8.
B7. (Does NAME’s/Last year did NAME’s) school serve school lunches? These are complete lunches that are free or cost the
same every day.
(1)
(0)
(r)
(d)

YES
NO  SKIP TO NEXT CHILD, IF LAST CHILD SKIP TO B8
REFUSED
DON’T KNOW

B7a. During the school year, about how many times a week does [FILL NAME] usually get a complete school lunch?
|__| ENTER NUMBER OF TIMES (RANGE 1-5)
(0)
NONE  SKIP TO NEXT CHILD, IF LAST CHILD SKIP TO B8
(r)
REFUSED
(d)
DON’T KNOW
B7b. Does [FILL NAME] get these lunches free, at a reduced price, or does he/she pay full price?
(1)
(2)
(3)
(r)
(d)

FREE
REDUCED PRICE
FULL PRICE
REFUSED
DON’T KNOW

17

CAPI: REPEAT B7 AND FOLLOW-UPS FOR EACH CHILD IN SCHOOL (B5 = 1 THROUGH 6, R, D,) OR (B5=0 AND B5a = 1, 2). FILL
IS TEXT ONLY
B8. (Do any children/Last year, did any children) in your household attend a school that serves school breakfasts? These
are complete breakfasts that are free or cost the same every day.
(1) YES
(0) NO  SKIP TO B9
(r) REFUSED  SKIP TO B9
(d) DON’T KNOW  SKIP TO B9
B8=1
B8a. Which children attend(ed) a school that serves breakfast?
FILL/ CHECK OFF NAME(S) ON ROSTER.
FILL [NAME] FROM EACH NAME CHECKED IN B8a. LOOP THROUGH B8b AND B8c FOR EACH NAME CHECKED AND THEN
MOVE TO B9.
B8b. ASK FOR EACH NAME CHECKED IN B8a: During the school year, about how many times a week does NAME usually
get a complete breakfast at school?
|__| ENTER NUMBER OF TIMES (RANGE 1-5)
(0)
NONE  SKIP TO NEXT CHILD OR B9 IF LAST CHILD
(r)
REFUSED
(d)
DON’T KNOW
B8c. Does NAME get these breakfasts free, at a reduced price, or does (he/she) pay full price?
(1)
(2)
(3)
(r)
(d)

FREE
REDUCED PRICE
FULL PRICE
REFUSED
DON’T KNOW

CAPI: ASK B9-B12 FOR EACH CHILD WITH B5=1 TO 6 (ATTENDING SCHOOL) OR B5a=1,2
B9. During the school year, where does NAME usually go right after school is over?
(1) YOUR HOME OR ANOTHER HOME (SUCH AS A FRIEND, RELATIVE, NEIGHBOR), WITH AN ADULT THERE  SKIP TO
B10
(2) YOUR HOME OR ANOTHER HOME, WITHOUT AN ADULT THERE  SKIP TO B10
(3) A PARK OR RECREATION PROGRAM
(4) A COMMUNITY OR CHURCH GROUP
(5) STAYED AT SCHOOL FOR AN AFTER-SCHOOL PROGRAM
(6) STAYED AT SCHOOL FOR TUTORING OR A SPECIAL CLASS
(7) SOME OTHER PLACE
(r) REFUSED
(d) DON’T KNOW
B9=3,4,5,6
B9a. Does NAME receive a snack from this program?
(1)
(0)
(r)
(d)

YES
NO
REFUSED
DON’T KNOW
18

IF B5a = 2 OR B6=2. FILL NAME FROM ROSTER AND LOOP THROUGH B10 AND B10a FOR EACH NAME BEFORE MOVING TO
B11
B10. ASK IF B6=2 (CHILD IS ON SUMMER BREAK): Does [NAME] get a free meal or snack at any summer program [IF A4=1
FILL: he/ IF A4=2 FILL: she] attends?
INTERVIEWER NOTE: if child attends summer camp, meals may be included in the total cost of the camp (i.e. not “free”).
(1)
(2)
(3)
(4)
(r)
(d)

YES, GETS FREE MEAL
NO, GETS FOOD BUT ITS NOT FREE SKIP TO B11
NO, DOES NOT GET FOOD  SKIP TO B11
DOES NOT ATTEND A SUMMER PROGRAM SKIP TO B11
REFUSED  SKIP TO B11
DON’T KNOW  SKIP TO B11

FILL NAME FROM ROSTER WHERE AGE LE 5. LOOP THROUGH B11 AND B11A BEFORE MOVING TO B12
CHILD CARE PROGRAMS: ASK B11 FOR EACH CHILD UP TO AGE 5.
B11. Does NAME attend a child care center, family day care home, Head Start, or Early Head Start?
IF NEEDED: Child care centers are places where care is provided in classrooms. Family day care homes are places where
care is provided in the provider’s home. Head Start is a pre-school program for children age 3 and older from lowincome families. Early Head Start is a program for children up to age 3.
(1)
(2)
(3)
(4)
(0)
(r)
(d)

CHILD CARE CENTER
FAMILY DAY CARE HOME
HEAD START
EARLY HEAD START
NO  SKIP TO B12
REFUSED  SKIP TO B12
DON’T KNOW  SKIP TO B12

IF B11 = 1, 2, 3, 4
B11a. How many meals does NAME usually receive from (his/her) child care provider PER WEEK?
|___|___| NUMBER MEALS (RANGE 0-30, D, R)
B11b. How many snacks PER WEEK does NAME usually receive from (his/her) child care provider?
|___|___| -NUMBER SNACKS (RANGE 0-30. D, R)

WIC PROGRAM
IF HH SIZE = 1 AND A4=1 SKIP TO B15.
IF HH SIZE = 1 AND A4=2 AND AGE > 50 SKIP TO B15.
ELSE ASK B12 – B14 SERIES.
Next are a few questions about the WIC program - the Women, Infants, and Children program. WIC provides healthy foods
and other services to low-income pregnant and breastfeeding women, infants, and children up to age 5. Before I ask these
questions, could you tell me…

19

B12. (IF HH size =1 FILL: Are you / IF HH size >1 FILL: Is anyone in your household) currently pregnant?
(1) YES
(0) NO → Skip to B13
(r) REFUSED → Skip to B13
(d) DON'T KNOW → Skip to B13
IF B12=1. LOOP UNTIL ALL NAMES ARE RECORDED.
B12a. Who is that? Anyone else?
_________ CAPI: POPULATE NAMES FROM ROSTER, CHECK ALL THAT APPLY
CAPI: FILL NAME FROM ROSTER WHERE A6< 2. LOOP THROUGH EACH APPLICABLE NAME THEN MOVE TO B14.
B13. ASK FOR EACH CHILD UP TO AGE 2, ELSE SKIP: Is NAME currently breastfeeding?
(1) YES
(0) NO
(r) REFUSED
(d) DON'T KNOW
B14. Is anyone in your household now receiving benefits from WIC?
(1)
(0)
(r)
(d)

YES
NO→ SKIP TO B15
REFUSED → SKIP TO B15
DON’T KNOW → SKIP TO B15

IF B14=1
B14a. Who is that? PROBE: Anyone else? (CHECK ALL THAT APPLY)
CAPI: POPULATE WITH NAMES FROM HH ROSTER,
(r) REFUSED
(d) DON’T KNOW
LOOP THROUGH B14b-B14e FOR EACH NAME FILLED. SET FLAG FOR NOT PREGNANT = B12a NOT CHECKED. REPEAT LOOP
FOR ADDITIONAL WIC PARTICIPANTS.
B14b. ASK ONLY IF NAME IS FEMALE (A4=2) AND A6 >12 AND NOT PREGNANT: Is [FILL NAME] receiving WIC for herself,
for a child, or for both herself and her child?
(1)
(2)
(3)
(r)
(d)

HERSELF
CHILD
BOTH
REFUSED
DON’T KNOW

B14b=1, 3,d,r
B14c. For how many months has [FILL NAME] received benefits from the WIC program?
INTERVIEWER: ENTER RESPONSE IN NUMBER FORMAT BELOW:
|__|__| ENTER NUMBER OF MONTHS OR YEARS (RANGE 1-36)
(r) REFUSED → SKIP TO B14d
(d) DON’T KNOW → SKIP TO B14d

20

B14c is not d or r
B14c1.
IS THAT IN … MONTHS OR YEARS
(1)
(2)

MONTHS
YEARS

CAPI: SOFT EDIT SCREEN HERE: “To confirm, I have [FILL NAME FROM THIS LOOP OF B14c-B14c1] as having received
benefits for [FILL NUMBER FROM B14c] [FILL UNIT FROM B14c1]. Is that correct?

ALL
COMMUNITY MEAL PROGRAMS
The next questions are about meals provided by community or government programs.
B15. (IF HH size= 1 FILL: Are you/ IF HH size > 1 FILL: Is anyone in your household) currently receiving any meals delivered to
your home from community programs, “Meals on Wheels”, or any other programs?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL
B16. In the past month, (IF HH size= 1 FILL: have you / IF HH size > 1 FILL: have you or other household members) gone to a
community program or senior center to eat prepared meals? IF NEEDED: This includes adult day care.
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW

SECTION C.

FOOD SHOPPING

The next questions are about where you get food.
ALL
C1. Where (do you/does your household) do most of your food shopping?
|_|_|_|_| STORE CODE FROM LIST → IF SELECTED “NOT ON LIST” CODE (ASSIGNED AS 99995) CONTINUE TO
C1_SPECIFY, ELSE SKIP TO C1b.
(r) REFUSED → SKIP TO C5
(d) DON’T KNOW → SKIP TO C5

21

C1=99995
C1_SPECIFY.
SPECIFY: ______________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW
C1_1. Where is that located? IF NEEDED: what street?
SPECIFY: ______________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW
C1_1. IF NEEDED: what city?
SPECIFY: ________________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW
CAPI: IF C1 IS ENTERED VIA STORE LIST CODE (LOOK-UP), THEN THE FOLLOWING STORE TYPES COUNT AS “SUPERMARKETS”
FOR SKIP PATTERN ASSUMPTIONS IN ITEMS THAT FOLLOW:
StoreType
SS
SM
LG

Store Type Descriptor
Super Store
Supermarket
Large Grocery Store

C1=99995
C1a. What kind of store is that? INTERVIEWER: SHOW RESPONDENT HAND CARD, IF NEEDED
(1) Supermarket
(2) Small grocery store
(3) Convenience store
(4) Discount or big box store like Target or Walmart

(5) Wholesale club like B.J.’s, Costco, or Sam’s Club
(6) OTHER – SPECIFY: ______ (STRING 150)
(r) REFUSED
(d) DON’T KNOW

FILL [STORE] FROM STORE NAME (STRING) IN C1 OR C1_SPECIFY.
C1b. What are your main reasons for shopping at [FILL STORE]? CHECK ALL THAT APPLY.
(1) LOW PRICES
(2) PRODUCE SELECTION
(3) MEAT DEPARTMENT
(4) VARIETY OF FOODS (GENERAL)
(5) VARIETY OF SPECIAL FOODS (SUCH AS GLUTEN FREE)
(5) CLOSE TO HOME
(6) LOYALTY/FREQUENT SHOPPER PROGRAM
(7) OTHER, SPECIFY: ___________________ (STRING 250)
(r) REFUSED
(d) DON’T KNOW

22

IF C1 DOES NOT HAVE STORE TYPE OF SS, SM, LG, OR MG OR C1A DOES NOT EQUAL 1
C2. Why (don’t (IF HH size=1 FILL: you)/ doesn’t (IF HH size>1 FILL: your household)) do most of your food shopping at a
large supermarket?
INTERVIEWER: RECORD VERBATIM RESPONSE BELOW THEN CODE ALL THAT APPLY IN C2A
(99) SPECIFY: ______________________(STRING 500)
(r) REFUSED
(d) DON’T KNOW
C2a. INTERVIEWER: CODE ALL THAT APPLY TO VERBATIM RESPONSE IN C2:
(12) NO SUPERMARKETS CLOSE BY
(13) NO TRANSPORTATION
(14) COSTS TOO MUCH TO GET THERE
(15) CAN’T FIND ETHNIC/SPECIALTY FOODS THERE
(16) NO CHILD CARE / ELDER CARE
(17) HOURS NOT CONVENIENT
(18) DON’T ACCEPT FOOD STAMPS / WIC VOUCHERS
(19) NOT TREATED WITH RESPECT
(20) OTHER STORES HAVE LOWER PRICES
(21) OTHER REASON
ALL
C3. In a typical month, where else (IF HH size=1 FILL: do you / IF HH size>1 FILL: does your household) shop for food?
|_|_|_|_| STORE CODE FROM LIST → IF SELECTED “NOT ON LIST” CODE (ASSIGNED AS 99995) CONTINUE TO
C3_SPECIFY, ELSE SKIP TO C3b
(r) REFUSED → SKIP TO C5
(d) DON’T KNOW → SKIP TO C5
C3=99995
C3_SPECIFY.
SPECIFY: ______________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW

C3=99995
C3_1.
Where is that located? IF NEEDED: what street?
SPECIFY: ______________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW

C3=99995
C3_1.
Where is that located? IF NEEDED: what city?
SPECIFY: ________________ (STRING 300)
(r) REFUSED
(d) DON’T KNOW
C3=99995
23

C3a. What kind of store is that? INTERVIEWER: SHOW RESPONDENT HAND CARD, IF NEEDED
(1) Supermarket
(5) Wholesale club like Costco, B.J.’s, or Sam’s Club
(2) Small grocery store
(6) OTHER ______________________ (STRING 100)
(3) Convenience store
(r) REFUSED
(4) Discount or big box store like Target or Walmart
(d) DON’T KNOW

C3 IS NOT d, r
FILL [STORE] FROM C3 STORE NAME STRING OR C3_SPECIFY.
C3b. What’s the main reason you shop at [STORE]?
(1) LOW PRICES / GOOD VALUE
(2) PRODUCE SELECTION
(3) MEAT DEPARTMENT
(4) QUALITY OF FOODS
(5) VARIETY OF FOODS (GENERAL)
(6) VARIETY OF SPECIAL FOODS (SUCH AS GLUTEN FREE)

(7) CLOSE TO HOME
(8) LOYALTY/FREQUENT SHOPPER PROGRAM
(9) OTHER, SPECIFY: _______ (STRING 300)
(r) REFUSED
(d) DON’T KNOW

ALL
C4. (Do you/does anyone in your household) ever shop anywhere else even for just a few items?
(1) YES
(0) NO → SKIP TO C5
(r) REFUSED → SKIP TO C5
(d) DON’T KNOW → SKIP TO C5
IF C4=1
C4a. In a typical month, how many different places (do you/does your household) shop for food or groceries?
|__|__| NUMBER (RANGE 01-25)
(r) REFUSED
(d) DON’T KNOW
ALL
FILL [STORE #1] C1 STORE NAME STRING OR C1_SPECIFY AND FILL [STORE #2] FROM C3 STORE NAME STRING OR
C3_SPECIFY.
C5. During the past 30 days, (did you/did anyone in your household) spend money on food at stores other than grocery
stores? CHECK ALL THAT APPLY.
INTERVIEWER: SHOW HAND CARD. Here are some examples of stores where you might buy food. Please do not include
[FILL STORE #1] and [FILL STORE#2] that you have already told me about.
(11) Convenience store (e.g., 7-11 or MiniMart)
(12) Discount or big box store like Target or Walmart
(13) Wholesale club like Costco, B.J.’s, or Sam’s Club
(14) Dollar store
(15) Bakeries
(16) Meat or Fish markets

(17) Produce stores or Vegetable stands
(18) OTHER – SPECIFY: _____________ (STRING 200)
(20) NO, DID NOT SPEND AT STORES OTHER THAN
GROCERY STORES
(r) REFUSED
(d) DON’T KNOW

24

ALL
C6. During the past 30 days, did (you/anyone in your household) go to a food pantry or food bank for groceries?
(1) YES
(0) NO → SKIP TO C7
(r) REFUSED → SKIP TO C7
(d) DON’T KNOW → SKIP TO C7
IF C6=1
C6a. What is the name of the food bank or food pantry?
(99) SPECIFY - NAME: _________________________________ (STRING 250)
(r) REFUSED
(d) DON’T KNOW
IF C6=1
C6b. Where is that located? IF NEEDED: What is the name of the street?
(99) SPECIFY – STREET:________________________ (STRING 200)
(r) REFUSED
(d) DON’T KNOW
IF C6=1
C6b1. Where is that located? IF NEEDED: What is the name of the city?
(99) SPECIFY –CITY:________________________ (STRING 200)
(r) REFUSED
(d) DON’T KNOW
ALL
C7. When in season, (do you/does your household) have a vegetable garden?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL
C8. Do you receive fruits or vegetables from anyone else’s garden?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL
C9. When in season, do you ever get food from a Farmer’s Market or farm stand?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW

25

ALL
C10.(Do you/ does anyone in your household) get food by hunting or fishing?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL
FILL [NAME OF STORE #1] FROM C1 STORE NAME STRING OR C1_SPECIFY, IF STORE NAME FIELD IN C1 IS d, r THEN INSERT
“the store where you buy most of your food” WHERE TEXT FILLS BELOW.
C11. Now I have questions about the store where you buy most of your food.
How do you usually get to [NAME OF STORE #1]?
(1) DRIVE OWN CAR → SKIP TO C12
(2) USE SOMEONE ELSE’S CAR → SKIP TO C12
(3) SOMEONE ELSE DRIVES ME → SKIP TO C12
(4) WALK → SKIP TO C11b
(5) BUS

(6) TAXI
(7) RIDE BICYCLE → SKIP TO C11b
(8) OTHER – SPECIFY: ____ (STRING 300) → SKIP TO C11b
(r) REFUSED → SKIP TO SKIP TO C11b
(d) DON’T KNOW → SKIP TO SKIP TO C11b

IF C11 = 5 or 6
FILL [NAME OF #1 STORE FROM C1]. IF STORE NAME FIELD IN C1 IS d, r THEN INSERT “the store where you buy most of
your food” WHERE TEXT FILLS BELOW.
C11a. How much do you pay out of pocket to get to [NAME OF #1 STORE] – one way?
$ |__|__|__|.|__|__| ONE-WAY COST (RANGE 0.00 – 100.00)
(r) REFUSED
(d) DON’T KNOW
IF C11 = 4-8, r,d
C11b. Do you or someone in your household have access to a car when you need one?
(1) YES
(0) NO
(r) REFUSED
(d) DON’T KNOW
ALL
FILL [NAME OF #1 STORE] FROM C1. IF STORE NAME FIELD IN C1 IS d, r THEN INSERT “the store where you buy most of your
food” WHERE TEXT FILLS BELOW.
C12. How long does it take to go one way from home to [NAME OF #1 STORE]?
|_______| NUMBER OF MINUTES TO GO ONE WAY (RANGE 1-90)
(r) REFUSED
(d) DON’T KNOW
CAPI: COMPLETE EACH QUESTION FOR ALL MEMBERS OF HOUSEHOLD. FILL NAME FROM ROSTER. LOOP THROUGH EACH
NAME BEFORE MOVING TO C14.
C13. How many times (IF HH size=1 FILL: do you / IF HH size>1 FILL: does NAME) eat dinner out during an average week?
This includes restaurants, fast-food, take-out, and ordering-in.”
|_____| TIMES PER WEEK (RANGE 0-7)
(r) REFUSED
(d) DON’T KNOW

26

CAPI: IF HH size > 1 ASK C14, ELSE SKIP TO CLOSE.
C14. How many times do you eat dinner out as a group during an average week?
|_____| TIMES PER WEEK (RANGE 0-7)
(r) REFUSED
(d) DON’T KNOW

Those are all the questions I have for this interview. Thank you. Now I’ll tell you about the information we
want you to collect during the week and explain the incentive you will receive for keeping track of the food
you get and completing our interviews.

CAPI: PRESENT LIST OF HOUSEHOLD MEMBERS AND EACH PERSON’S AGE IN GRID FOR INTERVIEWER AT THIS POINT. THIS IS
USED TO IDENTIFY WHO NEEDS EACH TYPE OF BOOK / WHICH NAMES ARE INCLUDED IN THE HOUSEHOLD DATA
COLLECTION TOOLS. THIS GRID IS DRIVEN OFF ALL HH MEMBERS IDENTIFIED WHERE FLAG2 = ON (ELIGIBLE FOR FOOD
BOOK).
INTERVIEWER: USE LIST BELOW TO LABEL HOUSEHOLD FOOD BOOK(S) AND MEALS AND SNACKS FORM.
AN EXAMPLE IS SHOWN BELOW FOR A 3 PERSON HH:
NAME
A1 (Initial Interview
MEMBER NAME)
A1_MEM1
A1_MEM2

AGE IN YEARS
RESPONSE TO A6
RESPONSE TO A6
RESPONSE TO A6

27

HIGHEST LEVEL OF EDUCATION
COMPLETED
CODE
11

DESCRIPTION
Less than 1st grade

12

1st, 2nd, 3rd or 4th grade

13

5th or 6th grade

14

7th or 8th grade

15

9th grade

16

10th grade

17

11th grade

18

12th grade, no diploma

19

High school graduate with diploma

20

High school graduate with GED or equivalent

21
22

1 or more years of college, but no degree
(Regular Jr. college/college/university)
Associate (2-Yr) college degree

23

Bachelor's degree (E.G., BA, AB, BS)

24

Master's or higher degree
(E.G., MA, MS, MENG, MED, MSW, MBA, JD, MD,
PH.D, ED.D)

Initial
Interview
Question
A10

TYPES OF STORES

Initial
Interview
Questions
C1a and C3a

What kind of store is that?
CODE DESCRIPTION
1

Supermarket

2

Small grocery store

3

Convenience store

4

Discount or big box store like Target or Walmart

5

Wholesale club like Costco, B.J.’s, or Sam’s Club

6

Other kind of store (please specify)

OTHER TYPES OF STORES

Initial
Interview
Question
C5

During the past 30 days, did you or anyone in your
household spend money on food at stores other
than grocery stores?
CODE DESCRIPTION
11

Convenience store (e.g., 7-11 or MiniMart)

12

Discount or big box store like Target or Walmart

13

Wholesale club like Costco, B.J.’s, or Sam’s Club

14

Dollar store

15

Bakeries

16

Meat or fish markets

17

Produce stores or vegetable stands

18

Other store (please specify)

RACE

Initial
Interview
Question
A8

Please choose one or more races that you
consider _____ to be…

CODE

DESCRIPTION

1

White

2

Black or African American

3

American Indian or Alaska Native

4

Asian

5

Native Hawaiian or Other Pacific Islander

6

Other (please specify)