Revised - Individuals/Households - Preparation for the Launch of the Summer Meals Study

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

APPENDIX E-6. Participant Caregiver Survey

The Food and Nutrition Service (FNS), U.S. Department of Agriculture (USDA), is conducting the Summer Meals Study to understand who receives meals at summer programs and why. On behalf of FNS, Westat, a research organization, is conducting this survey to understand:

• Where children spend their summer months;

• What role local programs play in providing meals and snacks to children in the summer months; and

• How these programs could be improved so more children can participate.

Your household has been chosen because you have a child between 5 and 18 years of age who attends the program at <SITE NAME> this summer. As an invited participant in this study, your household represents many other households similar to yours, so your answers are important.

This survey should be completed by the parent or caregiver of a child attending the summer program at <SITE NAME>.

Name of summer meals site

Participation is easy. Visit the secure survey website, enter your PIN and begin the survey.

SURVEY WEBSITE: https://www.SFSPsurvey.org

YOUR PIN: {#######}

You will receive $10 in cash as a token of our appreciation. Information provided in this survey will be kept private to the extent required by law.

We know you receive many survey requests in the mail and that your time is valuable. Taking part in this survey is voluntary. There are no penalties if you decide not to respond either to the survey as a whole or to any particular question. Regardless of whether you complete this survey, your child’s participation in the program at <SITE NAME>, or any government benefits or services received by you or anyone in your household, will not be affected.

If you have any questions, please call us toll-free at 1-800-XXX-XXXX.

Your opinion matters to us. Thank you for helping us with this important survey.

FOR TELEFORM ONLY:

Instructions for completing the survey

A computer will scan this questionnaire.

Please write clearly and use a black or blue pen only.

Please answer by filling in the circles completely like this:

not or or

If you make a mistake, mark through it with an X like this:

then fill in and draw a circle around the correct one like this:

SECTION A. ABOUT THE PROGRAM AT <SITE NAME>

A1. When did you first hear of the summer program at <SITE NAME>?

This year

Last year

A few years ago

Don’t remember

A2. How did you find out about the summer program at <SITE NAME> this summer? (CHECK ALL THAT APPLY.)

Flyer from child’s school

Flyer/Poster at local government or public assistance office

Flyer/Poster at local food bank

Flyer/Poster at church or other community group

Television or radio

Poster or billboard on a bus stop/bus/train

Toll-free hotline

Internet or social media

My child told me about it

My relative told me about it

My friend or neighbor told me about it

U.S. Department of Agriculture, Food and Nutrition Service (FNS) Site Finder

This survey

Other (PLEASE SPECIFY):

A2a. In the future, what would be the best way to provide you with information about summer programs that offer free meals to children ages 18 and younger? (CHECK ONLY ONE.)

Send information home from school with my child

Send information via mail

Send information via email

Send text message

Post information on social media

Poster or flyer at local government or public assistance office

Poster or flyer at local food bank

Poster or flyer at church or other community group

Television or radio advertisement

Post information on U.S. Department of Agriculture, Food and Nutrition Service (FNS) Site Finder

Other (PLEASE SPECIFY):

A3. In what month did you find out about the summer program at <SITE NAME>?

April

May

June

July

Other (PLEASE SPECIFY):

A3a. In the future, when is the best time to send you information about summer programs that offer free meals to children ages 18 and younger?

April

May

June

July

Other (PLEASE SPECIFY):

A4. Did the program materials include information about …? (CHECK ALL THAT APPLY.)

Program Schedule (dates and times for the program)

Location/Address

Types of activities offered

Program cost

Application procedures

Transportation options

Program offers free meals to children ages 18 and younger

Staff to child ratio

Safety and security precautions at the site

Who to contact for questions, with contact information

Other (PLEASE SPECIFY):

A4a. Did the program materials include all the details you needed to make a decision about sending your child to the program at <SITE NAME> this summer?

Yes

No, I followed-up with the program staff to get information about:

Program Schedule (dates and times for the program)

Location/Address

Types of activities offered

Program cost

Application procedures

Transportation options

Staff to child ratio

Who can receive free meals from the program safety and security precautions at the site

Who to contact for questions, with contact information

Other (PLEASE SPECIFY):

A4b. What information do parents and caregivers most need to know about the summer program to make a decision about sending your child there? (CHECK ALL THAT APPLY.)

Site location/address

Site schedule (dates and times for the program)

Program cost

Transportation options

Types of sports, games or activities provided

Types of meals provided (breakfast, lunch, supper, snacks)

Meal times (when meals and snacks are served)

Meal cost

Staff to child ratio

Safety and security precautions at the site

Who to contact for questions, with contact information

Other (PLEASE SPECIFY):

A5. About how far from your home is the program at <SITE NAME>?

Less than 1 mile

Between 1 mile and 3 miles

More than 3 miles but fewer than 5 miles

Between 5 miles and 10 miles

More than 10 miles

A6. Does the program at <SITE NAME> provide transportation?

Yes, transportation is provided for a separate fee

Yes, transportation is part of the overall program fee

Yes, free transportation is provided

No, the site does not provide transportation

Not sure

SECTION B. ABOUT THE CHILDREN IN YOUR HOUSEHOLD ATTENDING THE PROGRAM AT <SITE NAME> THIS YEAR

B1. How many children ages 18 and younger are now living in your household?

___ Number of children ages 18 and under in your household

B1a. Please tell us about the age, gender, ethnicity, and race for children ages 18 and younger that are living in your household.

	Age (years)	Is this child a boy or a girl?	Is this child Hispanic or Latino?	What is the race of this child? (SELECT ONE OR MORE.)
Child 1	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 2	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 3	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 4	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 5	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 6	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Child 7	___ years old	Boy Girl	Yes, Hispanic or Latino No, Not Hispanic or Latino	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

B2. Which of the following best describes where children in your household spend their summer months? (CHECK ALL THAT APPLY.)

At home with parent/sibling/guardian

At home with another relative

Home alone

At a relative’s/friend’s home

At a childcare/daycare home or center

At a summer camp or summer school

B3. Thinking about all children ages 18 and younger, how many attended/will attend a summer program this summer?

|___|___| Number of children ages 18 and younger at summer programs

B3a. Of these, how many attend the program at <SITE NAME> this summer?

|___|___| Number of children ages 18 and younger, in program at <SITE NAME>
this summer

If only one child in your household attends the program at <SITE NAME>, answer the questions in this section about that child. If more than one child in your household attends the program at <SITE NAME>, please answer the questions in this section about the child who had the most recent birthday. We do not mean the youngest child, just the child who had the last birthday.

B4. How old is this child?

|___|___| Age of child attending the program at <SITE NAME>

B5. Is this child a boy or a girl?

Boy

Girl

B6. What is your relationship to this child?

Birth or adoptive parent

Step parent

Foster parent

Brother or sister (including step/adoptive/foster)

Aunt or uncle

Grandparent or other relative

Other (PLEASE SPECIFY):

B7. Is this child of Hispanic, Latino, or Spanish origin?

Yes

No

B8. What is this child’s race? (CHECK ALL THAT APPLY.)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

B9. Besides attending the summer program at <SITE NAME>, which of the following best describes how this child usually spends his/her summer months? (CHECK ALL THAT APPLY.)

At home with parent/sibling/guardian

At home with another relative

At a relative’s/friend’s home

At a childcare/daycare home or center

At a summer camp or summer school

Home alone

Other (PLEASE SPECIFY):

B10. Besides attending the summer program at <SITE NAME>, did/will this child attend any other programs this summer?

Yes

No  GO TO B11

Not sure  GO TO B11

B10a. Do these summer programs serve meals or snacks? (CHECK ONLY ONE.)

Yes, meals and snacks are provided for a fee

Yes, meals and snacks are part of the program fee

Yes, free meals and snacks are provided

No, the programs do not provide meals or snacks

Not sure

B11. FOR SCHOOL BASED SITE ONLY: Does your child attend <THIS SCHOOL> during the school year?

Yes  GO TO B12

No

B11a. Besides attending the program at <SITE NAME>, does/will this child get summer meals at the school they attend?

Yes

No

Don’t know

B12. FOR SITES IN SEBTC STATES ONLY + USE STATE TERMINOLOGY FOR SEBTC, IF KNOWN: Do you have a summer electronic benefits transfer (EBT) card to use specifically to purchase food for your child/children during the summer months? This is usually called Summer Electronic Benefits Transfer for Children (SEBTC) or Summer EBT.

Yes

No

Don’t know

SECTION C. YOUR CHILD’S ATTENDANCE AND EXPERIENCE WITH THE SUMMER PROGRAM AT <SITE NAME>

If only one child in your household attends the program at <SITE NAME> answer the questions in this section about that child. If more than one child in your household attends the program at <SITE NAME>, please answer the questions in this survey about the child who had the most recent birthday. We do not mean the youngest child, just the child who had the last birthday.

C1. Is 2018 the first summer your child attended the summer program at <SITE NAME>?

Yes, first time attending this program

No, attended this program in previous years

C2. Who was involved in making the decision for your child to attend the program at <SITE NAME> this summer? (CHECK ALL THAT APPLY.)

Birth/Step/Foster Parent

Grandparent or other relative

Child

Brother/Sister/Cousin

Other (PLEASE SPECIFY):

C3. What were the main reasons for deciding to send your child to the program at <SITE NAME> this summer? (CHECK ALL THAT APPLY.)

The meals are free

The site’s opening hours are convenient

The site provides free transportation

The site location is convenient

Childcare is provided at the site

The site provides games and activities

The site offers a camp that my child wanted to attend (e.g., sports, music, science, etc.)

My child does not want to stay home

My child’s friends go to the site

My child can make new friends at the site

Proof of income is not required

Other reasons (PLEASE SPECIFY):

C4. Which of the following options are available to the child to get to and from the program at <SITE NAME> this summer? (CHECK ALL THAT APPLY.)

Family car, truck, or van

Bike

Public transit

Transportation provided by <SITE NAME>

Carpool

Walk

Other (PLEASE SPECIFY):

C4a. How did/does your child usually travel to and from the program at <SITE NAME>? (CHECK ONLY ONE.)

Walk alone or with friends

Walk with a parent or relative

Walk with brother/sister/cousin

Bike

Family car, truck, or van

Child takes public transportation alone or with friends

Child takes public transportation with parent or relative

Free transportation provided by the site

Paid transportation provided by the site/part of program fee

Other (PLEASE SPECIFY):

C5. Did/will the child attend the program at <SITE NAME> every week the program is offered this summer?

Yes, child did/will attend the program for all weeks that the program is/was
offered  GO TO C6

No, child did/will not attend the program for all weeks that the program is offered

Don’t know

C5a. How many weeks did/will your child attend the program at <SITE NAME>?

|___|___| Number of weeks child attended/will attend <SITE NAME> this summer

C5b. Thinking about your child’s attendance at the program at <SITE NAME> this summer, would you say that your child …

Attended the program as often as desired

Attended the program less often than desired

C5c. Why did/will your child not attend the program at <SITE NAME> for all weeks that the program was/is offered this summer? (CHECK ALL THAT APPLY.)

Visiting relatives/friends

At other summer programs

Others might think we can’t provide meals/snacks for your child

Only needy families should send children to the program every week

Friends not attending the program

Not enough activities to keep the child engaged

Prefer to be home some days/weeks

Do not like <MEAL 1> served at the site

Do not like <MEAL 2> served at the site

Do not like times when meals are served

Other (PLEASE SPECIFY):

C6. Thinking about your child’s attendance at the program at <SITE NAME> this summer, would you say that the number of days your child attended the program …

was about the same each week

varied/varies from week to week

C7. About how many days a week did/will your child usually attend the program at <SITE NAME> this summer?

Once or less than once a week

Two days each week

Three days each week

Four days each week

Five or more days each week

C8. Which of the following features would improve your child's attendance at the program at <SITE NAME>? (CHECK ALL THAT APPLY.)

Games and activities

Number of weeks the program is offered

Number of days each week the program is offered

Daily schedule (number of hours)

Walkable distance from home

Program cost

Shelter from heat and rain

Staff supervision

Having friends of child attending the program

Free transportation

Other (PLEASE SPECIFY):

None of the above

C9. In the weeks that your child attended the program at <SITE NAME> this summer, on how many days did your child usually eat meals and snacks? (CHECK ONE BOX ONLY.)

Everyday  GO TO C10

On most days

On some days

My child did not eat meals and snacks provided by the program at <SITE NAME>

C9a. What would have encouraged your child to eat more meals/snacks at <SITE NAME> this summer? (CHECK ALL THAT APPLY.)

If the site offered <MEAL NOT SERVED>

Better appearance of food

Better presentation of food

Better quality

Shelter from heat and rain

Healthier food

Shorter lines

Larger portion sizes

Fewer items on the menu

More information on the menus

More items on the menu

More hot meals

More variety of food

More information on the nutrition content of foods

More time to eat

No change is needed, I am satisfied with the meals/snacks

I don’t know enough about the food to answer this question

C10. In general, how would you rate the appearance of meals served by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the food served by the program

C11. In general, how would you rate the variety of foods served at meals by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the food served by the program

C12. In general, how would you rate the quality of foods served at meals by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the food served by the program

C13. In general, how would you rate the overall nutritional value of foods served at meals by the program at <SITE NAME> this summer?

Excellent

Good

Poor

I don’t know enough about the food by the program

C14. Overall, how satisfied or dissatisfied are you (the parent or caregiver) with the food served by the program at <SITE NAME> this summer?

Very Satisfied

Satisfied

Neither satisfied or dissatisfied

Dissatisfied

Very dissatisfied

I don’t know enough about the food to rate it

C15. Thinking about your experience with the program at <SITE NAME>, how satisfied or dissatisfied are you (the parent or caregiver) with the program this summer?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very Dissatisfied

I don’t know enough about the site to rate it

C16. If available, would you send your child to the program at <SITE NAME> next summer?

Yes  GO TO C17

No

Don’t know/Not sure

C16a. Which of the following are reasons your child may not participate in the program at <SITE NAME> next summer? (CHECK ALL THAT APPLY.)

Child's friends did not attend

Child not interested/refused to go

Activities do not appeal to the child

Was not open all day

Was not convenient and easy to get to

Location unsafe

No transportation

Didn’t provide lunch

Meals were not of high quality

Cost too much

Didn’t offer education or sports and recreational activities

Didn’t provide day care so adults in household could work

Inadequate supervision

Didn’t have a good reputation

He/she will attend another program

He/she will stay somewhere else during the day/for the Summer

Other (PLEASE SPECIFY):

C17. How likely is it that you would recommend the program at <SITE NAME> to other families with children?

Very likely

Moderately likely

A little likely

Not at all likely

C18. Is there anything else you would like to tell us about the summer meals site where your child receives meals this summer?

SECTION D. FOOD SITUATION IN YOUR HOUSEHOLD

The next questions are about the food situation in your household in the last 30 days and whether you were able to afford the food you need. For each statement or question below, please select one response that best describes your household’s food situation.

D1. In the last 30 days… (CHECK ONE BOX ONLY.)

We had enough of the kinds of food we wanted to eat  GO TO SECTION E

We had enough food but not always the kinds of food we wanted to eat

We sometimes did not have enough food to eat

We often did not have enough food to eat

D2. In the last 30 days, we worried whether our food would run out before we got money to buy more.

Often true

Sometimes true

Never true

Don’t know

D3. In the last 30 days, the food that we bought just didn’t last, and we didn’t have money to get more.

Often true

Sometimes true

Never true

Don’t know

D4. In the last 30 days, we couldn’t afford to eat balanced meals.

Often true

Sometimes true

Never true

Don’t know

D5. In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?

Yes

No  GO TO D6

Don’t know  GO TO D6

D5a. In the last 30 days, on how many days did this happen?

___ Days

D6. In the last 30 days, did you (the parent or caregiver) ever eat less than you felt you should because there wasn’t enough money for food?

Yes

No

Don’t know

D7. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?

Yes

No

Don’t know

D8. In the last 30 days, did you lose weight because there wasn’t enough money for food?

Yes

No

Don’t know

D9. In the last 30 days, did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food?

Yes

No  GO TO D10

Don’t know  GO TO D10

D9a. In the last 30 days, on how many days did this happen?

___ Days

The next questions are about the food situation of your children. For each statement or question, please select one response that best describes your children’s food situation.

D10. In the last 30 days we relied on only a few kinds of low-cost food to feed the child(ren) because we were running out of food.

Often true

Sometimes true

Never true

Don’t know

D11. In the last 30 days we couldn’t feed the child(ren) a balanced meal because we couldn’t afford it.

Often true

Sometimes true

Never true

Don’t know

D12. In the last 30 days my child(ren) were not eating enough because we could not afford enough food.

Often true

Sometimes true

Never true

Don’t know

D13. In the last 30 days did you ever cut the size of any of your child(ren)’s meals because there wasn’t enough money for food?

Yes

No

Don’t know

D14. In the last 30 days did your child(ren) ever skip meals because there wasn’t enough money for food?

Yes

No  GO TO D15

Don’t know GO TO D15

D14a. In the last 30 days, on how many days did this happen?

___ Days

D15. In the last 30 days was your child(ren) ever hungry but you just couldn’t afford more food?

Yes

No

Don’t know

D16. In the last 30 days did your child(ren) ever not eat for a whole day because there wasn’t enough money to buy food?

Yes

No

Don’t know

SECTION E. ABOUT YOU AND YOUR HOUSEHOLD

E1. How old are you?

18-29 years old

30-39 years old

40-49 years old

50-59 years old

60 or older

E2. Are you male or female?

Male

Female

E3. What language do you usually speak at home?

English

Spanish

Other (PLEASE SPECIFY):

E4. What is the highest level of school you have completed?

No schooling completed

Less than grade 12

12th grade

GED or alternative credential

Some college credit but no degree

Associate degree (for example: AA, AS)

Bachelor's degree (for example: BA, BS)

Master's degree (for example: MA, MS, MEng, MED, MSW, MBA)

Professional degree beyond bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)

Doctorate degree (for example: PhD, EdD)

E5. Were you born outside of the United States, Puerto Rico, or other U.S. territories?

Yes

No

E5a. How long have you lived in the United States?

less than 1 year

1 year but less than 5 years

5 years but less than 10 years

10 years or more

E6. Last month, were you …? (CHECK ONLY ONE.)

With a job or business but not at work

Not working at a job or business

Working at a job or business

Looking for work

E6a. What is the main reason you did not work last month?

Taking care of home/family

Going to school

Retired

Unable to work for health reasons

Disabled

On layoff/unemployed

On vacation

On strike

Other (PLEASE SPECIFY):

E7. In general, would you say your health is …?

Excellent

Very good

Good

Fair

Poor

E8. Including yourself, how many adults ages 19 and older are now living in this household?

|___|___| Number of people in the household

E8a. Of these, how many are adults over 60 years?

|___|___| Number of adults over 60 years

E9. In the last 30 days, has there been a change in the number of people living in your household?

Yes

No

E9a. What caused the change? (CHECK ALL THAT APPLY.)

Birth of child

New step, foster, or adopted child

Marriage/new partner

Separation or divorce

Family/boarder moving in

Family/boarder moving out

Other (PLEASE SPECIFY):

E10. In the past 12 months, did anyone in your household: (CHECK ALL THAT APPLY.)

Attend a Head Start program?

Attend a day care program or child care center that provides meals and snacks at no cost?

Receive free or reduced price lunch at school?

Receive free or reduced price breakfast at school?

Receive snacks at before or after school programs?

Receive food from a food pantry, food bank, or soup kitchen?

E11. In the past 12 months, did anyone in your household receive: (CHECK ALL THAT APPLY)

Financial assistance to pay rent or housing costs

Assistance from (STATE NAME FOR LIHEAP) to pay electric or gas utility bills

Help with paying medical expenses through (STATE NAME FOR MEDICAID)

Assistance from (STATE NAME FOR TANF)

Benefits from (STATE NAME FOR SNAP)

Benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

E12. Please indicate whether you or anyone in your household received income in the last 12 months from any of the following: (CHECK ALL THAT APPLY)

Wages, salary, commissions, bonuses, or tips

Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships

Interest, dividends, net rental income, royalty income, or income from estates and trusts

Social security or Railroad Retirement

Supplemental Security Income

Any public assistance or welfare payments from the state or local welfare office

Retirement, survivor, or disability pensions

Any other sources of income received regularly such as Veterans (VA) payments, unemployment compensation, child support, or alimony

E13. What was the total income received last month by you and other household members before taxes? Please include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, and so forth.

$ __________

E14. Which category best describes your total household income last year, before taxes or other deductions? (CHECK ONLY ONE)

under $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to 49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 or more

E15. Which of the following best describes your household’s current financial condition?

Very comfortable and secure

Able to make ends meet without much difficulty

Occasionally have some difficulty making ends meet

Tough to make ends meet but keeping your head above water

In over your head

E16. Did your name or address change recently?

No. We will send $10 to the name and address on the survey letter.

Yes. Please let us know where to send $10 for this survey.

NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

E17. Would you be available for a follow-up telephone interview in the next month or so? The interview will take about an hour and you will receive $20 as a token of appreciation.

No

Yes. Please let us know your contact information.

HOME NUMBER:

CELL PHONE NUMBER:

EMAIL ADDRESS:

E18. Because phone numbers and email addresses change over time, please tell us the name and contact information of two people who will know how to find you.

Contact Person # 1:

Phone Number for Contact Person # 1:

Contact Person # 2:

Phone Number for Contact Person # 2:

Thank you for participating in the Summer Meals Study

Public reporting burden for this collection of information is estimated to average 30 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. 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 Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.