National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX Y
NEW INSTRUMENTS FOR HOUSEHOLD TRAINING

__________________________________
THANK YOU FOR CHOOSING MCDONALD’S
TRY OUR NEW BANANA BREAD TODAY!
789 MAIN ST
WALTHAM, MA
02453
!!! THANK YOU !!!
TEL# 781 893 6640 Store# 1564
KS# 3

Mar 25’12 (Sun) 15:41

MFY SIDE 1
QTY
2
1
1

KVS Order 67

ITEM
MED COKE
ANGUS DELUXE MEAL
2 FILET-O-FISH

TOTAL
3.78
4.70
3.33

Subtotal
Tax
Take-Out Total

11.81
0.83
12.64

Cash Tendered
Change

20.00
7.36

MCDONALD’S 1564
APPLY AT WWW.MCSTATE.COM/1564
__________________________________

Foods and Drinks Brought into the Home
Complete one BLUE page for each PLACE where you got food that you brought home
(√) DAY you brought
food home

Mon

Tue

Wed

X Fri

Thu

Name of PLACE
where you got food:

Stop and Shop

Location:

127 Samoset Street, Plymouth, MA 02360

Sat

Sun

Name of PERSON who got Person1
the food:
(√) Did you . . .

Use store or manufacturer’s coupons?

Use a store loyalty card or a frequent shopper card?

Save your receipt?

(√) How did you pay? Check ALL that apply
 X Cash

Check

WIC amount: $ _______.__
SNAP EBT amount: $ _______.__

ALL

X yes

X no
X no

no

TAPE RECEIPT
HERE

(√) Did you SCAN the food and drinks?

yes

4 30
$ _______.______ 

Enter total paid including tax and tip

yes

Debit card
TANF EBT

Credit card

Free

None

X Some

List ALL foods and drinks you COULD NOT SCAN
Write size or amount
if known

Description (Please be as specific as possible)

How many?

(Ounces, grams, lbs, etc.)

Can of Hunt’s tomato sauce

8 ounces

1

Dinner roll 

1

*If you need more lines, use another Blue page.
QUESTIONS? Call 1-866-275-8659

Office Use

X

McDonald’s

________________________________
THANK YOU FOR CHOOSING MCDONALD’S

Self

TRY OUR NEW BANANA BREAD TODAY!
789 MAIN ST
WALTHAM, MA
02453
!!! THANK YOU !!!
TEL# 781 893 6640 Store# 1564

X
√

KS# 3

X

MFY SIDE 1
QTY
2
1
1

$

1 2.6 4

$

.

√

KVS Order 67

ITEM
MED COKE
ANGUS DELUXE MEAL
2 FILET-O-FISH

TOTAL
3.78
4.70
3.33

Subtotal
Tax
Take-Out Total

11.81
0.83
12.64

Cash Tendered
Change

20.00
7.36

MCDONALD’S 1564
APPLY AT WWW.MCSTATE.COM/1564
________________________________

X

Fries

Mar 25’12 (Sun) 15:41

Medium

1

—

Office Use

X

McDonald’s
Self
X
√
X

$

1 2.6 4

$

.

√
X

Angus Deluxe Meal

1

6.59

Fries

Medium

1

—

Diet Coke

Medium

1

—

2

3.33

1

1.89

Filet O’ Fish
Coke (regular)

Medium

Office Use