National Food Study Pilot

Appendix B-4

Income Worksheet

National Food Study Pilot

Agency: Economic Research Service

Contractor: Westat, Inc.

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

National Food Study Pilot

Income Worksheet

All household members 16 years of age or older will be asked to complete an electronic income worksheet.

The table below displays the sources of income household members will be asked about.

Income Source	HH Member
Earnings from work
Unemployment Compensation
Workers Compensation
TANF
Public Assistance (not including TANF)
Child Support
Alimony
Disability or SSI (Supplemental Security Income)
Social Security
Retirement and Pension Income
Investment Income
Other Income

This worksheet will help you to prepare for the final interview at the end of the survey week. We will ask your income to help us understand how much money you have available to spend on food. Completing this worksheet during the study will make the final interview go faster. We would like you to report all sources of income including earnings from work, unemployment compensation, welfare, child support, alimony, retirement, disability, investment and any other sources of income. You only need to report income that you have received in the last month.

Screenshots are captured for a fictional scenario.