National Food Study Pilot

I2. In this interview I’ll ask you about your household’s eating habits, dietary needs, health status, income and nonfood expenditures. This information is important to understanding your household’s food acquisitions. Taking part in this study is completely voluntary. You can skip any question you do not wish to answer or that makes you feel uncomfortable. Remember, 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 your family. Your responses will not affect any benefits or services you may receive from any government agency, now or in the future. It will take about 30 minutes to answer these questions. I’d like to begin now unless you have any questions for me. May I begin?

(1) YES, CONTINUE
(2) NO, RESCHEDULE ALTERNATE TIME
(3) NO, DECLINE TO TAKE PART/REFUSAL

Section A: # times prepare dinner at home in 7 days

A1. During the past 7 days, how many times did (you/ you or someone else in your family) prepare food for dinner or supper at home? Include times spent putting the ingredients together for a meal, but do not include heating up leftovers.

NUMBER: ____________ (Range 0-20)

(0) NEVER
(98) REFUSED
(97) DON'T KNOW

A1a. How often do you shop with a grocery list?

(1) Never
(2) Seldom
(3) Sometimes
(4) Most of the time
(5) Almost always
(98) REFUSED
(97) DON'T KNOW

[IF HH SIZE >1, ASK A2]

A2. During the past 7 days, how many meals did all or most of your family sit down and eat together? THIS INCLUDES MEALS EATEN AWAY FROM HOME.

NUMBER: ____________ (Range 0-30)

(98) REFUSED
(97) DON'T KNOW

Section B: How healthy is your diet?

B1. Thinking only about yourself, in general, how healthy is your overall diet? Would you say...

(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
(98) REFUSED
(97) DON'T KNOW

[IF HH SIZE >1, ASK B2]

B2. In general, how healthy is your family’s overall diet? Would you say . . . IF NEEDED: When we say “family” we mean all of the members of your household.

(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
(98) REFUSED
(97) DON'T KNOW

I am going to read a series of statements. Tell me whether you agree or disagree with each one of them.

B3a. It costs too much for (me/my family) to eat healthy foods. PROMPT: Do you agree or disagree?

(1) AGREE
(2) DISAGREE
(98) REFUSED
(97) DON'T KNOW

B3b. I’m too busy to take the time to prepare healthy foods. PROMPT: Do you agree or disagree?

(1) AGREE
(2) DISAGREE
(98) REFUSED
(97) DON'T KNOW

B3c. I don't think healthy foods taste good. PROMPT: Do you agree or disagree?

(1) AGREE
(2) DISAGREE
(98) REFUSED
(97) DON'T KNOW

[IF HH SIZE >1, ASK B3d]

B3d. People in my family don't think healthy foods taste good. PROMPT: Do you agree or disagree?

(1) AGREE
(2) DISAGREE
(98) REFUSED
(97) DON'T KNOW

B3e. The things that (I/my family) eat and drink now are healthy so there is no reason for (me/us) to make changes.

PROMPT: Do you agree or disagree?

(1) AGREE
(2) DISAGREE
(98) REFUSED
(97) DON'T KNOW

B4. Next I’m going to ask a few questions about the nutritional guidelines recommended for Americans by the federal government. Have you heard of MyPlate?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF B4 =1, ASK B4a]

B4a. Have you tried to follow the MyPlate guidelines?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

B5. Have you heard of MyPyramid?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF B5 in (0,r,d), ASK B5a, ELSE B6]

B5a. Have you heard of the Food Pyramid or the Food Guide Pyramid?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF B5=1, ASK B6]

B6. Have you looked up the MyPyramid plan for a (man/woman) your age on the internet?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF (B6=1) or (B5a = 1), ASK B6a, ELSE B10]

B6a. Have you tried to follow the MyPyramid Plan or Pyramid plan recommended for you?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

B10. Do you think you eat the right amount of fruits and vegetables now, or do you think you should eat more?

(1) EAT RIGHT AMOUNT
(2) SHOULD EAT MORE
(3) SHOULD EAT LESS
(98) REFUSED
(97) DON'T KNOW

B11. The “Nutrition Facts panel” of a food label is everything on this picture. [INTERVIEWERS TURN AROUND COMPUTER TO SHOW IMAGE OF NUTRIENT PANEL TO RESPONDENTS.] When choosing between different food items at the grocery store, how often do you use the Nutrition Facts panel to help you decide which item to buy? Would you say always, most of the time, sometimes, rarely, or never?

(1) ALWAYS
(2) MOST OF THE TIME
(3) SOMETIMES
(4) RARELY
(5) NEVER
(6) NEVER SEEN
(98) REFUSED
(97) DON'T KNOW

B12. In the past two months, have you participated in any events, lectures or demonstrations about how to shop for or prepare nutritious food and meals?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

B13. In the past two months, have you searched the internet for nutritional information or information about how to shop for or prepare nutritious foods and meals?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

Section C: [Vegetarian? Lactose-intolerant? Food allergies? Weight loss diet?]

C1. Do you consider (yourself/any members of your household) to be vegetarian?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF HHSIZE>1 and C1=1, ASK C1A, Response choices are a list of HH members. Else go to C2]

C1A. Who is that? (check all that apply)

PROBE: Anyone else?

(fill: Person 1)
(fill: Person 2)
(fill: Person N)

C2. (Are you/Is anyone in your household) lactose intolerant?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF HHSIZE>1 AND C2 = 1, ASK C2A, Response choices are a list of HH members. ELSE GO TO C3]

C2A. Who is that? (check all that apply)

PROBE: Anyone else?

(fill: Person 1)
(fill: Person 2)
(fill: Person N)

C3. (Do you/Does anyone in your household) have any food allergies?

IF NEEDED: A food allergy is a reaction causing a skin rash, hives, difficulty breathing, wheezing, or itching of the eyes, mouth, throat or skin.

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF HHSIZE>1 AND C3 = 1, ASK C3A, Response choices are a list of HH members. ELSE GO TO C4]

C3A. Who has food allergies? (check all that apply)

PROBE: Anyone else?

(fill: Person 1)
(fill: Person 2)
(fill: Person N)

[ASK C3b for each HH member checked in C3a.]

C3B. What foods (are you/is NAME) allergic to? (check all that apply)

	Person 1	Person 2	Person N
WHEAT	[ ]	[ ]	[ ]
Cow’s Milk	[ ]	[ ]	[ ]
EGGS	[ ]	[ ]	[ ]
FISH	[ ]	[ ]	[ ]
SHELLFISH	[ ]	[ ]	[ ]
CORN	[ ]	[ ]	[ ]
PEANUT	[ ]	[ ]	[ ]
OTHER NUTS	[ ]	[ ]	[ ]
SOY PRODUCTS	[ ]	[ ]	[ ]
Other	[ ]	[ ]	[ ]
Refused	[ ]	[ ]	[ ]
Don’t Know	[ ]	[ ]	[ ]

C4. (Are you/Is anyone in your household) on any kind of diet, either to lose weight or for some other health-related reason?

IF NEEDED: Examples of special diets include diet for weight loss, low carbohydrate, high protein, Atkins, low cholesterol, gluten-free, low sodium, diabetic diet, etc.

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF HHSIZE>1 AND C4 = 1, ASK C4A. ELSE GO TO D1]

C4A. Who is that? (check all that apply)

PROBE: Anyone else?

(fill: Person 1)
(fill: Person 2)
(fill: Person N)

Section D: [Health – excellent, good, etc.?] [Smoke? Chew tobacco?] [Height/weight]

D1. In general, would you say (your/NAME) health is…

	excellent	very good	good	fair	poor
(fill: Person 1)	( )	( )	( )	( )	( )
(fill: Person 2)	( )	( )	( )	( )	( )
(fill: Person N)	( )	( )	( )	( )	( )

D2. (Do you/does anyone who lives here) smoke cigarettes, cigars, or pipes, or chews tobacco?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[IF HHSIZE>1 AND D2 = 1, ASK D2A, Response choices are a list of HH members. ELSE GO TO D3]

D2A. Who smokes or chews tobacco? (check all that apply)

(fill: Person 1)
(fill: Person 2)
(fill: Person N)

The next questions are about the height and weight of each member of your household. I’ll start by asking about height.

D3. How tall (are you/NAME) without shoes?

IF AGE < 2 YRS: How tall is (NAME) when lying down and measured from head to toe?

ENTER # (IN FEET & INCHES OR METERS OR CENTIMETERS)

	Feet	Inches	Meters	Centimeters	Refused	Don’t Know
Person 1
Person 2
Person N

D4. How much (do you/does NAME) weigh without clothes or shoes?

ENTER POUNDS OR KILOGRAMS

	LBS	KG	Refused	Don’t Know
Person 1
Person 2
Person N

[INTERVIEWER: D4_ALT ARE IN CAPI ONLY:

NOTE: XX AND YY ARE CAPI FILLS BASED ON HEIGHT REPORTED IN D3. XX IS THE CUTOFF BETWEEN OVERWEIGHT AND OBESITY; YY IS THE CUTOFF BETWEEN NORMAL WEIGHT AND OVERWEIGHT. THE FILL VALUES POPULATE D4_CAT1 (OBESITYMEASURE) AND D4_CAT2 (OVERWEIGHTMEASURE).]

[IF AGE>18 AND D4_WEIGHT = r,d and D3 is not missing:]

D4_Alt1. (Do you/does NAME) weigh more or less than [XX] without clothes or shoes?

(1) MORE
(2) LESS
(98) REFUSED
(97) DON’T KNOW

[IF MORE, GO TO E1.]

D4_Alt2. (Do you/does NAME) weigh more or less than [YY] without clothes or shoes?

(1) MORE
(2) LESS
(98) REFUSED
(97) DON’T KNOW

[INSTRUCTION FOR PROGRAMMER: The half of respondents who did not get food security questions will answer section E and the half who did get the food section questions will go to section F directly.]

Section E: Food Security

These next questions are about the food eaten in your household in the last 30 days, and whether you were able to afford the food you need.

E1. Which of these statements best describes the food eaten in your household in the last 30 days?

(1) Enough of the kinds of food (I/we) want to eat
(2) Enough, but not always the kinds of food (I/we) want to eat
(3) Sometimes not enough to eat
(4) Often not enough to eat
(98) REFUSED
(97) DON’T KNOW

Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 30 days.

E2. The first statement is “(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.” Was that often true, sometimes true, or never true for (you/your household) in the last 30 days?

(1) OFTEN TRUE
(2) SOMETIMES TRUE
(3) NEVER TRUE
(98) REFUSED
(97) DON’T KNOW

E3. “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

(1) OFTEN TRUE
(2) SOMETIMES TRUE
(3) NEVER TRUE
(98) REFUSED
(97) DON’T KNOW

E4. “(I/We) couldn’t afford to eat balanced meals.” PROMPT: Was that often, sometimes, or never true for (you/your household) in the last 30 days?

(1) OFTEN TRUE
(2) SOMETIMES TRUE
(3) NEVER TRUE
(98) REFUSED
(97) DON’T KNOW

[IF (E1=3 or 4) or (E2=1 or 2) or (E3=1 or 2) or (E4=1 or 2) CONTINUE. OTHERWISE GO TO SECTION F.]

E5. In the last 30 days did (you/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?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF E5 = 1, ASK E5A]

E5a. In the last 30 days, how many days did this happen?

#DAYS: ____________ (Range 1-30)

(98) REFUSED
(97) DON’T KNOW

		YES	NO	REF	DK
E6	In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?	( )	( )	( )	( )
E7	In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?	( )	( )	( )	( )
E8	In the last 30 days, did you lose weight because there wasn't enough money for food?	( )	( )	( )	( )
E9	In the last 30 days, did (you/you or other adults in your household) ever not eat for a whole day because there wasn't enough money for food?	( )	( )	( )	( )

[IF E9 = Yes, ASK E9A]

E9A. In the last 30 days, how many days did this happen?

#DAYS: ____________ (Range 1-30)

(98) REFUSED
(97) DON’T KNOW

Section F: Household Income

F1. Next are questions about your household’s income. When we say “income” we mean earnings from work, unemployment, welfare, child support, retirement income, disability income, investment income, and any type of income even if you do not get it regularly.

[***FIRST PASS******]

[EARNINGS FROM WORK]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE HAD INCOME FROM “EARNINGS FROM WORK,” ASK F1_1. IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F1_2.

F1_1. According to the income worksheet, [FILL NAMES] had earnings from work in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F1_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F1_1, GO TO F2_1.

ELSE IF F1_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F1_2.

ELSE IF F1_1=0, 97, 98 ASK F1_2.

F1_2. Did {you/anyone [else] in your household} have earnings from work in the last month?

YES->GO TO F1_4

NO->GO TO F1_3

Don’t Know->GO TO F1_3

Refused->GO TO F1_3

F1_3. Did {you/anyone [else] in your household} have earnings from work in the last 12 months, that is, since (month) 1st of (YEAR)?

YES-> F1_4

NO->GO TO F2_1

Don’t Know->GO TO F2_1

Refused->GO TO F2_1

F1_4. Who had earnings from work {IF F1_2=1, SHOW: in the last month/IF F1_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[UNEMPLOYMENT COMPENSATION]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE HAD INCOME FROM “UNEMPLOYMENT COMPENSATION,” ASK F2_1. IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, GO TO F2_2.

F2_1. According to the income worksheet, [FILL NAMES] received income from unemployment compensation in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F2_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F2_1, GO TO F3_1.

ELSE IF F2_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING INCOME FROM THIS SOURCE, ASK F2_2.

ELSE IF F2_1=0, 97, 98 ASK F2_2.

F2_2. Did {you/anyone [else] in your household} receive income from unemployment compensation in the last month?

YES->GO TO F2_4

NO->GO TO F2_3

Don’t Know->GO TO F2_3

Refused->GO TO F2_3

F2_3. Did {you/anyone [else] in your household} receive income from unemployment compensation in the last 12 months?

YES->GO TO F2_4

NO->GO TO F3_1

Don’t Know->GO TO F3_1

Refused->GO TO F3_1

F2_4. Who received income from unemployment compensation {IF F2_2=1, SHOW: in the last month/IF F2_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[WORKERS COMPENSATION]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “WORKERS COMPENSATION,” ASK F3_1. IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F3_2.

F3_1. According to the income worksheet, [FILL NAMES] received income from workers compensation in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F3_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F3_1, GO TO F4_1.

ELSE IF F3_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F3_2.

ELSE IF F3_1=0, 97, 98 ASK F3_2.

F3_2. Did {you/anyone [else] in your household} receive income from workers compensation in the last month?

YES->GO TO F3_4

NO->GO TO F3_3

Don’t Know->GO TO F3_3

Refused->GO TO F3_3

F3_3. Did {you/anyone [else] in your household} receive income from workers compensation in the last 12 months?

YES->GO TO F3_4

NO->GO TO F4_1

Don’t Know->GO TO F4_1

Refused->GO TO F4_1

F3_4. Who received income from workers compensation {IF F3_2=1, SHOW: in the last month/IF F3_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[TANF]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE HAD INCOME FROM “TANF,” ASK F4_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, GO TO F4_2.

F4_1. According to the income worksheet, [FILL NAMES] received income from the Temporary Assistance for Needy Families (TANF) program or {STATE TANF PROGRAM NAME} in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F4_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F4_1, GO TO F5_1.

ELSE IF F4_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F4_2.

ELSE IF F4_1=0, 97, 98 ASK F4_2.

F4_2. Did {you/anyone [else] in your household} receive income from the Temporary Assistance for Needy Families (TANF) program or {STATE TANF PROGRAM NAME} in the last month?

YES->GO TO F4_4

NO->GO TO F4_3

Don’t Know->GO TO F4_3

Refused->GO TO F4_3

F4_3. Did {you/anyone [else] in your household} receive income from the TANF program in the last 12 months?

YES->GO TO F4_4

NO->GO TO F5_1

Don’t Know->GO TO F5_1

Refused->GO TO F5_1

F4_4. Who received income from the TANF program {IF F4_2=1, SHOW: in the last month/IF F4_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[GENERAL ASSISTANCE]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “GENERAL ASSISTANCE,” ASK F5_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F5_2.

F5_1. According to the income worksheet, [FILL NAMES] received income from general assistance {other than TANF} in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F5_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F5_1, GO TO F6_1.

ELSE IF F5_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F5_2.

ELSE IF F5_1=0, 97, 98 ASK F5_2.

F5_2. {Other than TANF, did/Did} {you/anyone [else] in your household} receive income from General Assistance, General Relief, or the GA program in the last month?

YES->GO TO F5_4

NO->GO TO F5_3

Don’t Know->GO TO F5_3

Refused->GO TO F5_3

F5_3. Did {you/anyone [else] in your household} receive income from General Assistance, General Relief, or the GA program in the last 12 months?

YES->GO TO 5_4

NO->GO TO F6_1

Don’t Know->GO TO F6_1

Refused->GO TO F6_1

F5_4. Who received income from General Assistance, General Relief, or the GA program {IF F5_2=1, SHOW: in the last month/IF F5_2=2, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[CHILD SUPPORT]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “CHILD SUPPORT,” ASK F6_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F6_2.

F6_1. According to the income worksheet, [FILL NAMES] received income from child support in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F6_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F6_1, GO TO F7_1.

ELSE IF F6_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F6_2.

ELSE IF F6_1=0, 97, 98 ASK F6_2.

F6_2. Did {you/anyone [else] in your household} receive income from child support in the last month?

YES->GO TO F6_4

NO->GO TO F6_3

Don’t Know->GO TO F6_3

Refused->GO TO F6_3

F6_3. Did {you/anyone [else] in your household} receive income from child support in the last 12 months?

YES->GO TO F6_4

NO->GO TO F7_1

Don’t Know->GO TO F7_1

Refused->GO TO F7_1

F6_4. Who received income from child support {IF F6_2=1, SHOW: in the last month/IF F6_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[ALIMONY]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “ALIMONY,” ASK F7_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F7_2.

F7_1. According to the income worksheet, [FILL NAMES] received income from alimony in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F7_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F7_1, GO TO F8_1.

ELSE IF F7_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F7_2.

ELSE IF F7_1=0, 97, 98 ASK F7_2.

F7_2. Did {you/anyone [else] in your household} receive income from alimony in the last month?

YES->GO TO F7_4

NO->GO TO F7_3

Don’t Know->GO TO F7_3

Refused->GO TO F7_3

F7_3. Did {you/anyone [else] in your household} receive income from alimony in the last 12 months?

YES->GO TO F7_4

NO->GO TO F8_1

Don’t Know->GO TO F8_1

Refused->GO TO F8_1

F7_4. Who received income from alimony {IF F7_2=1, SHOW: in the last month/IF F7_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS RESPONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[DISABILITY OR SSI]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “DISABILITY OR SSI,” ASK F8_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F8_2.

F8_1. According to the income worksheet, [FILL NAMES] received disability income or the Supplemental Security Income (SSI) in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F8_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F8_1, GO TO F9_1.

ELSE IF F8_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F8_2.

ELSE IF F8_1=0, 97, 98 ASK F8_2.

F8_2. Did {you/anyone [else] in your household} receive disability income or Supplemental Security Income (SSI) in the last month?

YES->GO TO F8_4

NO->GO TO F8_3

Don’t Know->GO TO F8_3

Refused->GO TO F8_3

F8_3. Did {you/anyone [else] in your household} receive disability income or SSI in the last 12 months?

YES->GO TO F8_4

NO->GO TO F9_1

Don’t Know->GO TO F9_1

Refused->GO TO F9_1

F8_4. Who received disability income or SSI {IF F8_2=1, SHOW: in the last month/IF F8_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

FOR EACH PERSON CONFIRMED AT F8_1 OR SELECTED AT F8_4, ASK F8_5. ELSE GO TO F9_1.

F8_5. What was the source of that income received by {NAME}? SELECT ALL THAT APPLY.

SOCIAL SECURITY DISABILITY RELIEF (SSDI)
BLACK LUNG BENEFITS
SSI
OTHER (SPECIFY: ____________________)

[SOCIAL SECURITY]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “SOCIAL SECURITY,” ASK F9_1.

IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F9_2.

F9_1. According to the income worksheet, [FILL NAMES] received income from social security in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F9_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F9_1, GO TO F10_1.

ELSE IF F9_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F9_2.

ELSE IF F9_1=0, 97, 98 ASK F9_2.

F9_2. Did {you/anyone [else] in your household} receive income from social security in the last month?

YES->GO TO F9_4

NO->GO TO F9_3

Don’t Know->GO TO F9_3

Refused->GO TO F9_3

F9_3. Did {you/anyone [else] in your household} receive income from social security in the last 12 months?

YES->GO TO F9_4

NO->GO TO F10_1

Don’t Know->GO TO F10_1

Refused->GO TO F10_1

F9_4. Who received income from social security {IF F9_2=1, SHOW: in the last month/IF F9_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[RETIREMENT AND PENSIONS]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “RETIREMENT AND PENSIONS,” ASK F10_1. IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F10_2.

F10_1. According to the income worksheet, [FILL NAMES] received pensions and retirement income in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F10_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F10_1, GO TO F11_1.

ELSE IF F10_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F10_2.

ELSE IF F10_1=0, 97, 98 ASK F10_2.

F10_2. Did {you/anyone [else] in your household} receive pensions and retirement income in the last month?

YES->GO TO F10_4

NO->GO TO F10_3

Don’t Know->GO TO F10_3

Refused->GO TO F10_3

F10_3. Did {you/anyone [else] in your household} receive pensions and retirement income in the last 12 months?

YES->GO TO F10_4

NO->GO TO F11_1

Don’t Know->GO TO F11_1

Refused->GO TO F11_1

F10_4. Who received pensions and retirement income {IF F10_2=1, SHOW: in the last month/IF F10_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

FOR EACH PERSON CONFRIMED AT F10_1 OR SELECTED AT F10_4, ASK F10_5. ELSE GO TO F11_1.

F10_5. What was the source of that income received by {NAME}? SELECT ALL THAT APPLY.

SOCIAL SECURITY RETIREMENT BENEFITS (SSA)
PENSIONS
OTHER RETIREMENT INCOME

[INVESTMENT]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “INVESTMENT,” ASK F11_1. IF INCOME WORKSHEET INDICATED THAT NO ONE REPORTED INCOME FROM THIS SOURCE, ASK F11_2.

F11_1. According to the income worksheet, [FILL NAMES] received investment income in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF F11_1=1 AND ALL HOUSEHOLD MEMBERS AGES 16 OR ABOVE ARE LISTED AT F11_1, GO TO F12_1.

ELSE IF F11_1=1 AND IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS HAVING EARNINGS FROM WORK, ASK F11_2.

ELSE IF F11_1=0, 97, 98 ASK F11_2.

F11_2. Did {you/anyone [else] in your household} receive investment income in the last month?

YES->GO TO F11_4

NO->GO TO F11_3

Don’t Know->GO TO F11_3

Refused->GO TO F11_3

F11_3. Did {you/anyone [else] in your household} receive investment income in the last 12 months?

YES->GO TO F11_4

NO->GO TO F12_1

Don’t Know->GO TO F12_1

Refused->GO TO F12_1

F11_4. Who received investment income {IF F11_2=1, SHOW: in the last month/IF F11_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

[OTHER INCOME]

IF INCOME WORKSHEET INDICATED THATAT LEAST ONE PERSON AGES 16 OR ABOVE RECEIVED INCOME FROM “OTHER,” ASK F12_1.

F12_1. According to the income worksheet, [FILL NAMES] received income from other sources in the last month or the last year. Is that correct?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

IF THERE WAS AT LEAST ONE PERSON AGES 16 OR ABOVE WHO WAS NOT INDICATED AS RECEIVING INCOME FROM “OTHER,” OR ANSWERED DK/REF TO F12_1, ASK F12_2. ELSE GO TO F12_1.

F12_2. Did {you/anyone [else] in your household} receive income from other sources in the last month?

YES->GO TO F12_4

NO->GO TO F12_3

Don’t Know->GO TO F12_3

Refused->GO TO F12_3

F12_3. Did {you/anyone in your household} receive income from other sources in the 12 months?

YES->GO TO F12_4

NO->GO TO F13_0a

Don’t Know->GO TO F13_0a

Refused->GO TO F13_0a

F12_4. Who received income from other sources {IF F12_2=1, SHOW: in the last month/IF F12_3=1, SHOW: in the last 12 months}?

SHOW HOUSEHOLD MEMBERS >=16 AS REPSONSE OPTIONS FOR INTERVIEWERS TO CHOOSE FROM

FOR EACH PERSON SELECTED AT F12_4, ASK F12_5. ELSE GO TO F13_0a.

F12_5. What was the source of that income received by {NAME}? Anything else? SELECT ALL THAT APPLY.

STRIKE BENEFITS
FUEL ASSISTANCE
ROOMERS, LODGERS, OR TENANTS
EDUCATIONAL GRANTS
INSURANCE SETTLEMENT PAYMENTS
VETERANS AFFAIRS BENEFITS
LOTTERY OR OTHER GAMBLING WINNINGS
TRUST FUND PAYMENT
EMPLOYMENT BONUSES
REFUSED
DON’T KNOW

***********START SECOND PASS************

[EARNINGS FROM WORK]

IF F1_1=1, THEN ASK F13_0A AND F13_0B FOR ALL NAMES SHOWN IN F1_1. ELSE GO TO F13.

F13_0A. According to the income worksheet, {NAME} received {AMOUNT} in earnings from work {in the last month/in the last year}. Does that sound about right?

[PROGRAMMER NOTE: IF {NAME} REPORTED INCOME FOR THE LAST MONTH, SHOW “in the last month”. IF {NAME} REPORTED INCOME FOR THE LAST YEAR, SHOW “in the last year.”

(1) YES SKIP TO F13_0B1
(0) NO GO TO F13_0B
(98) REFUSED GO TO F13_0B
(97) DON’T KNOWGO TO F13_0B

F13_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

PROGRAMMER NOTE: IF {NAME} REPORTED INCOME FOR THE LAST MONTH, SHOW “in the last month”. IF {NAME} REPORTED INCOME FOR THE LAST YEAR, SHOW “in the last year.”

$______________________

IF F13_0A=1 OR F13_0B=NOT MISSING THEN ASK F13_OB1. ELSE GO TO INSTRUCTION BEFORE F13.

F13_0b1. To your best knowledge, is that before taxes or after taxes?

BEFORE TAXES
AFTER TAXES

(98) REFUSED

(97) DON’T KNOW

IF F1_2=1 OR F1_3=1, THEN ASK F13. ELSE GO TO SKIP INSTRUCTION BEFORE F14.

FOR EACH PERSON SELECTED AT F1_4, ASK F13-F13_5.

F13. What is the easiest way for you to tell us {NAME}’s earnings from work; hourly, weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Hourly
Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F13_1. How much did {NAME} receive {per hour/per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in earnings from work?

$_____________

IF F13 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F13_2. ELSE GO TO SKIP INSTRUCTION BEFORE F13_2a.

F13_2. {IF F1_2=1, ASK: How many payments did you receive in the last month?/ IF F1_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

IF F13 IS HOURLY ASK F13_2A. ELSE GO TO SKIP INSTRUCTION BEFORE F13_3.

F13_2A. {IF F1_2=1ASK: How many hours did {NAME} work in the last pay period?/IF F1_3=1, ASK: How many hours did {NAME} work in a typical pay period?}

____________HOURS

F13_2B. {IF F1_2=1, ASK: How many pay periods were there in the last month?/ IF F1_3=1, ASK: How many pay periods were there in a typical month?}

____________HOURS

IF F13=MONTHLY, QUARTERLY, SEMI-ANNUALLY, YEARLY, GO TO F13_5. ELSE CALCULATE VERIFICATION TOTAL AND ASK F13_3.

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F13=HOURLY, VERIFICATION AMOUNT=F13_1*F13_2A*F13_2b.

IF F13=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F1_2=1 THEN VERIFICATION AMOUNT=F13_1*F13_2.

IF F13=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F1_3=1 THEN VERIFICATION AMOUNT=(F13_1*F13_2)/12.]

F13_3. According to our calculations, {NAME} received [TOTAL] altogether from earnings from work {IF F1_2=1, SHOW: in the last month/IN F1_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F13_5
NOASK F13_4
DON’T KNOWASK F13_4
REFUSEDASK F13_4

F13_4. What is your best estimate of the correct total amount {NAME} received {IF F1_2=1, SHOW: in the last month/IF F1_3=1, SHOW: per month in the last 12 months} before taxes?

$___________________________

F13_5. To your best knowledge, is that before taxes or after taxes?

BEFORE TAXES
AFTER TAXES

(98) REFUSED

(97) DON’T KNOW

[UNEMPLOYMENT COMPENSATION]

IF F2_1=1, THEN ASK F14_0A AND F14_0B FOR ALL NAMES SHOWN IN F2_1. ELSE GO TO F14.

F14_0A. According to the income worksheet, {NAME} received {AMOUNT} from unemployment compensation {in the last month/in the last year}. Does that sound about right?

[PROGRAMMER NOTE: IF {NAME} REPORTED INCOME FROM THIS SOURCE FOR THE LAST MONTH, SHOW “in the last month”. IF {NAME} REPORTED INCOME FROM THIS SOURCE FOR THE LAST YEAR, SHOW “in the last year.”

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F14
(0) NO GO TO F14_0B
(98) REFUSED GO TO F14_0B
(97) DON’T KNOWGO TO F14_0B

F14_0B. What is your best estimate of the correct total amount {NAME} received {in the last month/in the last year}?

$______________________

IF F2_2=1 OR F2_3=1, THEN ASK F14. ELSE GO TO SKIP INSTRUCTION BEFORE F15.

FOR EACH PERSON SELECTED AT F2_2, ASK F14-F14_4.

F14. What is the easiest way for you to tell us {NAME}’s income from unemployment compensation; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F14_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in unemployment compensation?

$_____________

IF F14 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F14_2. ELSE GO TO F15.

F14_2. {IF F2_2=1, ASK: How many payments did you receive in the last month?/IF F2_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F14=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F2_2=1 THEN VERIFICATION AMOUNT=F14_1*F14_2.

IF F14=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F2_3=1 THEN VERIFICATION AMOUNT=(F14_1*F14_2)/12.]

F14_3. According to our calculations, {NAME} received [TOTAL] altogether from unemployment compensation {IF F2_2=1, SHOW: in the last month/IF F2_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F15
NOASK F14_4
DON’T KNOWASK F14_4
REFUSEDASK F14_4

F14_4. What is your best estimate of the correct total amount {NAME} received {IF F2_2=1, SHOW: in the last month/IF F2_3=1, SHOW: per month in the last 12 months}?

$___________________________

[WORKERS COMPENSATION]

IF F3_1=1, THEN ASK F15_0A AND F15_0B FOR ALL NAMES SHOWN IN F3_1. ELSE GO TO F15.

F15_0A. According to the income worksheet, {NAME} received {AMOUNT} from workers compensation {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F15
(0) NO GO TO F15_0B
(98) REFUSED GO TO F15_0B
(97) DON’T KNOWGO TO F15_0B

F15_0B. What is your best estimate of the correct total amount {NAME} received {in the last month/in the last year}?

$______________________

IF F3_2=1 OR F3_3=1, THEN ASK F15. ELSE GO TO SKIP INSTRUCTION BEFORE F16.

FOR EACH PERSON SELECTED AT F3_2, ASK F15-F15_4.

F15. What is the easiest way for you to tell us {NAME}’s income from workers compensation; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F15_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in workers compensation?

$_____________

IF F15 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F15_2. ELSE GO TO F16.

F15_2. {IF F3_2=1, ASK: How many payments did you receive in the last month?/IF F3_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F15=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F3_2=1 THEN VERIFICATION AMOUNT=F15_1*F15_2.

IF F15=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F3_3=1 THEN VERIFICATION AMOUNT=(F15_1*F15_2)/12.]

F15_3. According to our calculations, {NAME} received [TOTAL] altogether from workers compensation {IF F3_2=1, SHOW: in the last month/IF F3_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F16
NOASK F15_4
DON’T KNOWASK F15_4
REFUSEDASK F15_4

F15_4. What is your best estimate of the correct total amount {NAME} received {IF F3_2=1, SHOW: in the last month/IF F3_3=1, SHOW: per month in the last 12 months}?

$___________________________

[TANF]

IF F4_1=1, THEN ASK F16_0A AND F16_0B FOR ALL NAMES SHOWN IN F4_1. ELSE GO TO F16.

F16_0A. According to the income worksheet, {NAME} received {AMOUNT} from TANF {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F16
(0) NO GO TO F16_0B
(98) REFUSED GO TO F16_0B
(97) DON’T KNOWGO TO F16_0B

F16_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

[PROGRAMMER NOTE: IF {NAME} REPORTED INCOME FROM THIS SOURCE FOR THE LAST MONTH, SHOW “in the last month”. IF {NAME} REPORTED INCOME FROM THIS SOURCE, FOR THE LAST YEAR, SHOW “in the last year.”

$______________________

IF F4_2=1 OR F4_3=1, THEN ASK F16. ELSE GO TO SKIP INSTRUCTION BEFORE F17.

FOR EACH PERSON SELECTED AT F4_2, ASK F16-F16_4.

F16. What is the easiest way for you to tell us {NAME}’s income from TANF; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F16_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in TANF?

$_____________

IF F16 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F16_2. ELSE GO TO F17.

F16_2. {IF F4_2=1, ASK: How many payments did you receive in the last month?/IF F4_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F16=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F4_2=1 THEN VERIFICATION AMOUNT=F16_1*F16_2.

IF F16=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F4_3=1 THEN VERIFICATION AMOUNT=(F16_1*F16_2)/12.]

F16_3. According to our calculations, {NAME} received [TOTAL] altogether from TANF {IF F4_2=1, SHOW: in the last month/IF F4_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F17
NOASK F16_4
DON’T KNOWASK F16_4
REFUSEDASK F16_4

F16_4. What is your best estimate of the correct total amount {NAME} received {IF F4_2=1, SHOW: in the last month/IF F4_3=1, SHOW: per month in the last 12 months}?

$___________________________

[GENERAL ASSISTANCE]

IF F5_1=1, THEN ASK F17_0A AND F17_0B FOR ALL NAMES SHOWN IN F5_1. ELSE GO TO F17.

F17_0A. According to the income worksheet, {NAME} received {AMOUNT} from the General Assistance program {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F17
(0) NO GO TO F17_0B
(98) REFUSED GO TO F17_0B
(97) DON’T KNOWGO TO F17_0B

F17_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F5_2=1 OR F5_3=1, THEN ASK F17. ELSE GO TO SKIP INSTRUCTION BEFORE F18.

FOR EACH PERSON SELECTED AT F5_2, ASK F17-F17_4.

F17. What is the easiest way for you to tell us {NAME}’s income from the General Assistance program; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F17_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in the General Assistance program?

$_____________

IF F17 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F17_2. ELSE GO TO F18.

F17_2. {IF F5_2=1, ASK: How many payments did you receive in the last month?/IF F5_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F17=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F5_2=1 THEN VERIFICATION AMOUNT=F17_1*F17_2.

IF F17=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F5_3=1 THEN VERIFICATION AMOUNT= (F17_1*F17_2)/12.]

F17_3. According to our calculations, {NAME} received [TOTAL] altogether from the General Assistance program {IF F5_2=1, SHOW: in the last month/IF F5_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F18
NOASK F17_4
DON’T KNOWASK F17_4
REFUSEDASK F17_4

F17_4. What is your best estimate of the correct total amount {NAME} received {in the last month/per month in the last 12 months}?

$___________________________

[CHILD SUPPORT]

IF F6_1=1, THEN ASK F18_0A AND F18_0B FOR ALL NAMES SHOWN IN F6_1. ELSE GO TO F18.

F18_0A. According to the income worksheet, {NAME} received {AMOUNT} from child support {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F18
(0) NO GO TO F18_0B
(98) REFUSED GO TO F18_0B
(97) DON’T KNOWGO TO F18_0B

F18_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F6_2=1 OR F6_3=1, THEN ASK F18. ELSE GO TO SKIP INSTRUCTION BEFORE F19.

FOR EACH PERSON SELECTED AT F6_2, ASK F18-F18_4.

F18. What is the easiest way for you to tell us {NAME}’s income from child support; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F18_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in child support?

$_____________

IF F18 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F18_2. ELSE GO TO F19.

F18_2. {IF F6_2=1, ASK: How many payments did you receive in the last month?/IF F6_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F18=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F6_2=1 THEN VERIFICATION AMOUNT=F18_1*F18_2.

IF F18=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F6_3=1 THEN VERIFICATION AMOUNT=(F18_1*F18_2)/12.]

F18_3. According to our calculations, {NAME} received [TOTAL] altogether from child support {IF F6_2=1, SHOW: in the last month/IF F6_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F19
NOASK F18_4
DON’T KNOWASK F18_4
REFUSEDASK F18_4

F18_4. What is your best estimate of the correct total amount {NAME} received {IF F6_2=1, SHOW: in the last month/IF F6_3=1, SHOW: per month in the last 12 months}?

$___________________________

[ALIMONY]

IF F7_1=1, THEN ASK F19_0A AND F19_0B FOR ALL NAMES SHOWN IN F7_1. ELSE GO TO F19.

F19_0A. According to the income worksheet, {NAME} received {AMOUNT} from alimony {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F19
(0) NO GO TO F19_0B
(98) REFUSED GO TO F19_0B
(97) DON’T KNOWGO TO F19_0B

F19_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F7_2=1 OR F7_3=1, THEN ASK F19. ELSE GO TO SKIP INSTRUCTION BEFORE F20.

FOR EACH PERSON SELECTED AT F7_2, ASK F19-F19_4.

F19. What is the easiest way for you to tell us {NAME}’s income from alimony; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F19_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in alimony?

$_____________

IF F19 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F19_2. ELSE GO TO F20.

F19_2. {IF F7_2=1, ASK: How many payments did you receive in the last month?/IF F7_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F19=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F7_2=1 THEN VERIFICATION AMOUNT=F19_1*F19_2.

IF F19=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F7_3=1 THEN VERIFICATION AMOUNT=(F19_1*F19_2)/12.]

F19_3. According to our calculations, {NAME} received [TOTAL] altogether from alimony {IF F7_2=1, SHOW: in the last month/IF F7_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F20
NOASK F19_4
DON’T KNOWASK F19_4
REFUSEDASK F19_4

F19_4. What is your best estimate of the correct total amount {NAME} received {IF F7_2=1, SHOW: in the last month/IF F7_3=1, SHOW: per month in the last 12 months}?

$___________________________

[DISABILITY OR SSI]

IF F8_1=1, THEN ASK F20_0A AND F20_0B FOR ALL NAMES SHOWN IN F8_1. ELSE GO TO F20.

F20_0A. According to the income worksheet, {NAME} received {AMOUNT} from disability or SSI {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F20
(0) NO GO TO F20_0B
(98) REFUSED GO TO F20_0B
(97) DON’T KNOWGO TO F20_0B

F20_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F8_2=1 OR F8_3=1, THEN ASK F20. ELSE GO TO SKIP INSTRUCTION BEFORE F21.

FOR EACH PERSON SELECTED AT F8_4, ASK F20-F20_4.

F20. What is the easiest way for you to tell us {NAME}’s income from disability or SSI; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F20_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in disability income?

$_____________

IF F20 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F20_2. ELSE GO TO F21.

F20_2. {IF F8_2=1, ASK: How many payments did you receive in the last month?/IF F8_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F20=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F8_2=1 THEN VERIFICATION AMOUNT=F20_1*F20_2.

IF F20=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F8_3=1 THEN VERIFICATION AMOUNT=(F20_1*F20_2)/12.]

F20_3. According to our calculations, {NAME} received [TOTAL] altogether from disability {IF F8_2=1, SHOW: in the last month/IF F8_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F21
NOASK F20_4
DON’T KNOWASK F20_4
REFUSEDASK F20_4

F20_4. What is your best estimate of the correct total amount {NAME} received {IF F8_2=1, SHOW: in the last month/IF F8_3=1, SHOW: per month in the last 12 months}?

$___________________________

[SOCIAL SECURITY]

IF F9_1=1, THEN ASK F21_0A AND F21_0B FOR ALL NAMES SHOWN IN F9_1. ELSE GO TO F21.

F21_0A. According to the income worksheet, {NAME} received {AMOUNT} from social security {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F21
(0) NO GO TO F21_0B
(98) REFUSED GO TO F21_0B
(97) DON’T KNOWGO TO F21_0B

F21_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F9_2=1 OR F9_3=1, THEN ASK F21. ELSE GO TO SKIP INSTRUCTION BEFORE F22.

FOR EACH PERSON SELECTED AT F9_4, ASK F21-F21_4.

F21. What is the easiest way for you to tell us {NAME}’s income from social security; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F21_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in social security?

$_____________

IF F21 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F21_2. ELSE GO TO F22.

F21_2. {IF F9_2=1, ASK: How many payments did you receive in the last month?/IF F9_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F21=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F9_2=1 THEN VERIFICATION AMOUNT=F21_1*F21_2.

IF F21=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F9_3=1 THEN VERIFICATION AMOUNT=(F21_1*F21_2)/12.]

F21_3. According to our calculations, {NAME} received [TOTAL] altogether from social security {IF F9_2=1, SHOW: in the last month/IF F9_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F22
NOASK F21_4
DON’T KNOWASK F21_4
REFUSEDASK F21_4

F21_4. What is your best estimate of the correct total amount {NAME} received {IF F9_2=1, SHOW: in the last month/IF F9_3=1, SHOW: per month in the last 12 months}?

$___________________________

[PENSIONS AND RETIREMENT]

IF F10_1=1, THEN ASK F22_0A AND F22_0B FOR ALL NAMES SHOWN IN F10_1. ELSE GO TO F22.

F22_0A. According to the income worksheet, {NAME} received {AMOUNT} from pensions and retirement {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F22
(0) NO GO TO F22_0B
(98) REFUSED GO TO F22_0B
(97) DON’T KNOWGO TO F22_0B

F22_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F10_2=1 OR F10_3=1, THEN ASK F22. ELSE GO TO SKIP INSTRUCTION BEFORE F23.

FOR EACH PERSON SELECTED AT F10_4, ASK F22-F22_4.

F22. What is the easiest way for you to tell us {NAME}’s income from pensions and retirement; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F22_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in pensions and retirement?

$_____________

IF F22 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F22_2. ELSE GO TO F23.

F22_2. {IF F10_2=1, ASK: How many payments did you receive in the last month?/IF F10_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F22=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F10_2=1 THEN VERIFICATION AMOUNT=F22_1*F22_2.

IF F22=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F10_3=1 THEN VERIFICATION AMOUNT=(F22_1*F22_2)/12.]

F22_3. According to our calculations, {NAME} received [TOTAL] altogether from pensions and retirement {IF F10_2=1, SHOW: in the last month/IF F10_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F23
NOASK F22_4
DON’T KNOWASK F22_4
REFUSEDASK F22_4

F22_4. What is your best estimate of the correct total amount {NAME} received {IF F10_2=1, SHOW: in the last month/IF F10_3=1, SHOW: per month in the last 12 months}?

$___________________________

[INVESTMENT INCOME]

IF F11_1=1, THEN ASK F23_0A AND F23_0B FOR ALL NAMES SHOWN IN F11_1. ELSE GO TO F23.

F23_0A. According to the income worksheet, {NAME} received {AMOUNT} from investment income {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F23
(0) NO GO TO F23_0B
(98) REFUSED GO TO F23_0B
(97) DON’T KNOWGO TO F23_0B

F23_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F11_2=1 OR F11_3=1, THEN ASK F23. ELSE GO TO SKIP INSTRUCTION BEFORE F24.

FOR EACH PERSON SELECTED AT F11_4, ASK F23-F23_4.

F23. What is the easiest way for you to tell us {NAME}’s investment income; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F23_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in investment?

$_____________

IF F23 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F23_2. ELSE GO TO F24.

F23_2. {IF F11_2=1, ASK: How many payments did you receive in the last month?/IF F11_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F23=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F11_2=1 THEN VERIFICATION AMOUNT=F23_1*F23_2.

IF F23=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F11_3=1 THEN VERIFICATION AMOUNT=(F23_1*F23_2)/12.]

F23_3. According to our calculations, {NAME} received [TOTAL] altogether from investment {IF F11_2=1, SHOW: in the last month/IF F11_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO F24
NOASK F23_4
DON’T KNOWASK F23_4
REFUSEDASK F23_4

F23_4. What is your best estimate of the correct total amount {NAME} received {IF F11_2=1, SHOW: in the last month/IF F11_3=1, SHOW: per month in the last 12 months}?

$___________________________

[OTHER INCOME]

IF F12_1=1, THEN ASK F24_0A AND F24_0B FOR ALL NAMES SHOWN IN F12_1. ELSE GO TO F24.

F24_0A. According to the income worksheet, {NAME} received {AMOUNT} from other income sources {in the last month/in the last year}. Does that sound about right?

(1) YES SKIP TO SKIP INSTRUCTION BEFORE F24
(0) NO GO TO F24_0B
(98) REFUSED GO TO F24_0B
(97) DON’T KNOWGO TO F24_0B

F24_0B. What is your best estimate of the correct total amount {NAME} received {in the last month}?

$______________________

IF F12_2=1 OR F12_3=1, THEN ASK F24. ELSE GO TO NEXT SECTION].

FOR EACH PERSON SELECTED AT F12_4, ASK F24-F24_4.

F24. What is the easiest way for you to tell us {NAME}’s income from other sources; weekly, every other week, twice a month, monthly, quarterly, semi-annually or yearly?

Weekly
Every other week
Twice a month
Monthly
Quarterly
Semi-annually
Yearly

F24_1. How much did {NAME} receive {per week/every other week/twice a month/per month/per quarter/semi-annually/per year} in other sources of income?

$_____________

IF F24 IS WEEKLY, EVERY OTHER WEEK, TWICE A MONTH, ASK F24_2. ELSE GO TO NEXT SECTION.

F24_2. {IF F12_2=1, ASK: How many payments did you receive in the last month?/IF F12_3=1, ASK: How many payments did you receive in the last 12 months?}

____________PAYMENTS

[CAPI COMPUTE A LAST MONTH OR MONTHLY INCOME FOR VERIFICATION PURPOSE:

IF F24=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F12_2=1 THEN VERIFICATION AMOUNT=F24_1*F24_2.

IF F24=WEEKLY, EVERY OTHER WEEK, TWICE A MONTH AND F12_3=1 THEN VERIFICATION AMOUNT=(F24_1*F24_2)/12.]

F24_3. According to our calculations, {NAME} received [TOTAL] altogether from other sources of income {IF F12_2=1, SHOW: in the last month/IF F12_3=1, SHOW: per month in the last 12 months}. Does that sound about right?

YESGO TO NEXT SECTION
NOASK F24_4
DON’T KNOWASK F24_4
REFUSEDASK F24_4

F24_4. What is your best estimate of the correct total amount {NAME} received {IF F12_2=1, SHOW: in the last month/IF F12_3=1, SHOW: per month in the last 12 months}?

$___________________________

[IF HOUSEHOLD CURRENTLY RECEIVED SNAP (Q11 IN SCREENER=1 OR Q1 IN INITIAL INTERIVEW=1), ASK F25, ELSE GO TO INSTRUCTION BEFORE F26]

F25. Did your household receive a SNAP issuance during the last week?

1 YESGO TO F25A

2 NOGO TO INSTRUCTION BEFORE F26

3 DON’T KNOWGO TO INSTRUCTION BEFORE F26

4 REFUSEDGO TO INSTRUCTION BEFORE F26

F25A. How much did you receive from SNAP during the past week?

$____________

[IF HOUSEHOLD IS ON WIC (Q12 FROM SCREENER=1 OR B14 FROM INITIAL INTERIVEW=1, ASK F16. ELSE GO TO NEXT SECTION)

F26. Did your household receive a WIC issuance during the last week?

1 YES

2 NO

3 DON’T KNOW

4 REFUSED

F26A. How much did you receive from WIC during the past week?

$____________

F27. (Do you/Does your household) have $2,000 or more in cash, checking accounts, saving accounts, money markets, or other assets that are easily converted to cash? INTERVIEWER: WE WANT TO KNOW IF TOTAL LIQUID ASSETS ARE $2000 OR MORE.

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF F27= 1 then Ask F27a]

F27a. (Do you/Does your household) have $3,000 or more in cash, checking accounts, saving accounts, money markets, or other assets that are easily converted to cash? INTERVIEWER: WE WANT TO KNOW IF TOTAL LIQUID ASSETS ARE $3000 OR MORE.

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

Section G: Household expenses last month

The next questions are about your household expenses last month. Household expenses do not include business expenses, so you should not include business expenses in your responses.

G1. (Do you/Does your household) rent or own your home?

(1) RENT
(2) OWN
(3) OTHER, DO NOT PAY FOR HOUSING
(98) REFUSED
(97) DON’T KNOW

[IF G1 = 1, 2, ASK G1A, G1B]

G1a. How much (do you/does your household) pay for (rent/mortgage)?

$_________.____

(98) REFUSED
(97) DON’T KNOW

G1b. (Let me confirm.) Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(98) REFUSED
(97) DON’T KNOW

IF G1=1 or 2, GO TO SKIP INSTRUCTION BEFORE G1D.

G1c. Is this public housing – that is, is it owned by a local public housing authority or other public agency?

DO NOT INCLUDE MILITARY HOUSING.

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF (G1=2) GO TO G2a, ELSE GO TO G1d]

G1d. Is the rent here subsidized by the Federal, State, or Local government? By that I mean, is the government paying part of the cost? DO NOT INCLUDE MILITARY HOUSING.

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

G2a. How much do (you/your household) pay for homeowners or renters insurance?

$ ____________. ____  GO TO G2b

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G2A has Amount, ASK G2b]

G2b. (Let me confirm.) Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY

(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(98) REFUSED
(97) DON’T KNOW

G2c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

[IF OWN HOME (G1=2) ASK G3a/b/c, OTHERWISE GO TO G4

G3a. How much (do you/does your household) pay for real estate or property tax on your home?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G3A has Amount, ASK G3b]

G3b. (Let me confirm.) Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(98) REFUSED

G3c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G4. (Do you/does anyone in your household) own or lease a car or truck?

(1) YES, OWN
(2) YES, LEASE
(3) OWN AND LEASE
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF G4=No, Refused, or Don't know, Ask G4a]

G4_1. How many vehicles (do you/does your household) own or lease?

NUMBER: ____________

(98) REFUSED
(97) DON’T KNOW

G4a. Last month, how much did (you/your household) pay for public transportation or vehicle rentals?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G4A has Amount, ASK G4b]

G4b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G4c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G5a. Last month, how much did (you/your household) pay for electricity?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G5A has Amount, ASK G5b]

G5b. Let me confirm. Is that per month, twice per month, every other week, per week, or per year

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G5c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G6a. Last month, how much did (you/your household) pay for gas, oil, wood, or other heating fuels?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G6A has Amount, ASK G6b]

G6b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G6c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G7a. Last month, how much did (you/ your household) pay for sewer maintenance and/or garbage collection?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G7A has Amount, ASK G7b]

G7b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G7c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G8a. Last month, how much (did you/did your household) pay for health insurance? Please include payments for health insurance that are automatically deducted from your pay.

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G8A has Amount, ASK G8b]

G8b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G8c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G9a. Last month, how much did (you/ your household) pay for health insurance co-pays? These are payments that you make to physicians or hospitals when your insurance pays most of the bill.

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G9A has Amount, ASK G9b]

G9b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G9c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G10a. Last month, how much did (you/your household) pay for physician or hospital bills not paid by insurance?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G10A has Amount, ASK G10b]

G10b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G10c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G11a. Last month, how much did (you/your household) pay for prescription drugs?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G11A has Amount, ASK G11b]

G11b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G11c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

[IF (G9a>0) or (G10a>0) or (G11a>0), ASK G11d:]

G11d. Last month, how much of (your/your household’s) out-of-pocket medical expenses were spent for household members who are older than age 59 or are disabled?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

G11e. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G12a. Last month, how much did (you/your household) pay for child care?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G12A has Amount, ASK G12b]

G12b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G12c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G13a. Last month, how much did (you/your household) pay in child support?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G13A has Amount, ASK G13b]

G13b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY

(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G13c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G14a. Last month, how much did (you/your household) pay for adult care?

$ ____________. ____

NOTHING
(98) REFUSED
(97) DON’T KNOW

[IF G14A has Amount, ASK G14b]

G14b. Let me confirm. Is that monthly, twice per month, every other week, weekly, or annually?

(1) PER MONTH OR MONTHLY
(2) TWICE PER MONTH
(3) EVERY OTHER WEEK
(4) EVERY WEEK
(5) PER YEAR OR ANNUALLY
(97) DON’T KNOW
(98) REFUSED

G14c. ALREADY REPORTED WITH OTHER EXPENSE?

(1) YES
(0) NO

G15a. Over the past month, has your household had any unusually large and unexpected expenses that affected your spending on food during the study week?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

Section H: Major life events

My next questions are about major life events

H1. Has there been a change in the number of people living in your household over the past 3 months?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF H1= 1 then ASK H1a]

H1a. What caused that change? CHECK ALL THAT APPLY.

(1) BIRTH OF CHILD
(2) NEW STEP, FOSTER OR ADOPTED CHILD
(3) SEPARATION OR DIVORCE
(4) DEATH OF HOUSEHOLD MEMBER
(5) MARRIAGE
(6) NEW PARTNER
(7) A CHILD, PARENT, OTHER RELATIVE MOVING IN OR OUT OF THE HOUSEHOLD
(8) OTHER
(98) REFUSED
(97) DON’T KNOW

H2. Have you (or anyone in your family) been diagnosed with a major illness or disability in the past 3 months?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF H2= 1 then ASK H2a]

H2a. Was that someone in your household or someone outside your household?

(1) HOUSEHOLD MEMBER(S)
(2) FAMILY MEMBER(S) OUTSIDE HOUSEHOLD
(3) BOTH HOUSEHOLD MEMBERS AND NON-HOUSEHOLD MEMBERS
(98) REFUSED
(97) DON’T KNOW

H3. (Have you/Has anyone in your household) changed jobs in the past 3 months?

(1) YES
(0) NO
(98) REFUSED
(97) DON’T KNOW

[IF H3=1 ASK H3a/b]

H3a. Who was that? Anyone else?

NAME(S): ___________________

(98) REFUSED
(97) DON’T KNOW

H3b. FOR EACH PERSON NAMED IN H3a: (Do you/Does NAME) now earn more, less, or about the same as before changing jobs?

(1) MORE
(2) LESS
(1) ABOUT THE SAME
(98) REFUSED
(97) DON’T KNOW

H4. Which of the following best describes (your/your household’s) financial condition?

(1) Very comfortable and secure
(2) Able to make ends meet without much difficulty
(3) Occasionally have some difficulty making ends meet
(4) Tough to make ends meet but keeping your head above water
(5) In over your head

Next I'll read a list of financial practices. Please tell me whether your household does them never, rarely, sometimes, usually, or always. [IF THE RESPONDENT IS NOT ABLE TO RESPOND FOR THE HOUSEHOLD, REQUEST THAT THEY ANSWER FOR THEMSELVES.]

H4a. How often (do you/does your household) review your bills for accuracy?

(1) Never
(2) Rarely
(3) Sometimes
(4) Usually
(5) Always
(6) NOT APPLICABLE
(98) REFUSED
(97) DON’T KNOW

H4b. How often (do you/does your household) pay your bills on time?

(1) Never
(2) Rarely
(3) Sometimes
(4) Usually
(5) Always
(6) NOT APPLICABLE
(98) REFUSED
(97) DON’T KNOW

H4c. How often (do you/does your household) pay more than the “minimum payment” due on your credit card bills?

(1) Never
(2) Rarely
(3) Sometimes
(4) Usually
(5) Always
(6) NOT APPLICABLE
(98) REFUSED
(97) DON’T KNOW

[IF QUESTION H4=3,4,5 CONTINUE TO H5a, OTHERWISE SKIP TO SECTION I]

Next are questions about difficulties people sometimes have in meeting their essential household expenses for such things as mortgage or rent payments, utility bills, or important medical care.

H5a. During the past 6 months, has there been a time when (you/your household member) could not pay your mortgage or rent, electricity or gas utilities, or important medical expenses?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

H5b. In the past 6 months, (were you/was your household) evicted from a home or apartment for not paying the rent or mortgage?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

H5c. In the past 6 months, has there been a time when (you/your household) could not pay the full amount of the gas, oil, or electricity bills?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

H5d. During the last 6 months, (have you/has anyone in your household) used a cash advance service on any of your credit cards?

(1) YES
(0) NO
(2) NOT APPLICABLE
(98) REFUSED
(97) DON'T KNOW

H5e. In the last 6 months, (have you/has anyone in your household) used a payday loan or other high interest rate loan?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

Section I: Residences

READ: My last questions are about your current and previous residence.

I1. In what month and year did (you/NAME) move into this (house/apartment/mobile home)?

	CHECK IF ALWAYS LIVED HERE	Month (1-12)	Year (1910-2016)
Person 1	[ ]	_ _	_ _ _ _
Person 2	[ ]	_ _	_ _ _ _
Person N	[ ]	_ _	_ _ _ _

[IF I1 = ALWAYS]

I1a. So (you/NAME) lived here since birth - is that correct?

	Yes	No	REFUSED	DON’T KNOW
Person 1	( )	( )	( )	( )
Person 2	( )	( )	( )	( )
Person N	( )	( )	( )	( )

[IF NAME DID NOT LIVE IN CURRENT HOME SINCE BIRTH:]

I2. Was (your/NAME’s) previous home also located in (THIS STATE), or was it in some other state?

	YES, SAME STATE	NO, NOT SAME STATE	REFUSED	DON’T KNOW
Person 1	( )	( )	( )	( )
Person 2	( )	( )	( )	( )
Person N	( )	( )	( )	( )

[IF I2 = 0, ASK I2a]

I2a. What state was that?

	State Abb.	NOT IN U.S.	REFUSED	DON’T KNOW
Person 1	_ _	( )	( )	( )
Person 2	_ _	( )	( )	( )
Person N	_ _	( )	( )	( )

I3.

If I2=1:

Were you born in (THIS STATE)?

If I2=0:

Were you born in (I2a STATE)?

	Yes	No	REFUSED	DON’T KNOW
Person 1 <state>	( )	( )	( )	( )
Person 2 <state>	( )	( )	( )	( )
Person N <state>	( )	( )	( )	( )

[IF I3 = 0]

I3a. Where (were you/was NAME) born?

	State Abb.	NOT IN U.S.	REFUSED	DON’T KNOW
Person 1	_ _	( )	( )	( )
Person 2	_ _	( )	( )	( )
Person N	_ _	( )	( )	( )

[ASK IF I3a= “NOT IN U.S.”]

I4. (Are you /Is NAME) a U.S. citizen?

PROBE: We are not interested in your immigration status. We are asking about citizenship because it helps to determine whether people are eligible for (STATE SNAP PROGRAM).

	Yes	No	REFUSED	DON’T KNOW
Person 1	( )	( )	( )	( )
Person 2	( )	( )	( )	( )
Person N	( )	( )	( )	( )

[INTERVIEWER: ASK I5 IF HOUSEHOLD DID NOT CONSENT TO ADMINSITRATION DATA LINK, OTHERWISE GO TO INSTRUCTION BEFORE I6]

I5. At the beginning of the week, you did not consent to allowing us to obtain information from state agencies about your receipt of food program benefits. Any data that we obtain will be kept strictly confidential. Do we have your permission to obtain your administrative data from state agencies?

(1) YES
(0) NO
(98) REFUSED
(97) DON'T KNOW

[INTERVIEWER: ASK I6 IF HOUSEHOLD CONSENTED TO ADMINSITRATIVE DATA LINK EITHER AT THE BEGINNING OF WEEK OR I5=1 AND HOUSEHOLD RECEIVE SNAP (Q1=1 FROM INITIAL INTERVIEW). OTHERWISE GO TO SECTION J

I6.

(IF B1=1 OR (Q1=1 AND HHSIZE=1), SHOW:) Can you give me the number that is on your [insert State EBT card name] card? This number will be used for purposes of matching to program administrative records only.

(IF B1=2,R,D, SHOW: ) Can you give me the numbers that are on your [insert State EBT card name] cards? The card numbers will be used for purposes of matching to program administrative records only.

[IF NEEDED: again, any data that we obtain will be used for statistical purposes only and your data will be kept strictly confidential].

SNAP CASE NUMBER 1: ________________________

SNAP CASE NUMBER 2: _______________________

SNAP CASE NUMBER 3: _______________________

That completes your final interview. Thank you for taking the time to answer these questions.

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Author	Andrew Heller
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File Created	2021-01-23

National Food Study Pilot

Alternative Data Collection Method (ADCM) for Collecting FoodAPS-Like Data Study (aka the National Food Study Pilot)

B7 Final Interview