SNAP Participants (Respondents)

APPENDIX B.1: SURVEY INSTRUMENT - ENGLISH

OMB Approval No. XXXX-XXXX

Approval Expires: XX/XX/20XX

Food and Your Household

You are selected to participate in a survey that is being conducted by the U.S. Department of Agriculture, Food and Nutrition Service (FNS) to understand people’s grocery shopping behaviors.

The survey asks questions about foods purchased and meals prepared for your household.

By household, we mean people who live with you and with whom you purchase and prepare food.

• If you live alone, please answer all the questions for yourself.

• If you live with others but purchase foods and prepare meals for yourself only, please answer all the questions for yourself.

• If you live with others and food purchases and meal preparation are shared with people in your household, please answer all questions for your household.

There are no right or wrong answers. If you are unsure of how to answer a question, please give the best answer you can and make a comment in the margin. Your answers will not be shared outside the study team, except as otherwise required by law. Your answer will be combined with everyone else’s and reported as overall findings. Information provided by all invited participants will be combined to answer questions like these:

• Where do people shop for groceries?

• How do people decide where to shop?

• What types of foods are available to people where they shop?

• What is the general food situation in America’s households?

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 made a mistake, mark through it with an X like this

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

The survey will take about 25 minutes to fill out. Please remember to answer questions on both the front and back of each page.

After you are done, return it in the enclosed postage-paid envelope within the next 7 days. When we receive your completed survey, we will send you $20 as a token of appreciation. If you need additional information, please call 1-XXX-XXX-XXXX or email us at XXXX.com.

Thank you.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number.  The valid OMB control number for this information collection is XXXX-XXXX.  The time required to complete this information collection is estimated to average 25 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.

SECTION A: SHOPPING FOR GROCERIES

When answering questions, please think about your household. By household, we mean people who live with you and with whom you purchase and prepare food.

If you live alone, please answer only for yourself.

This section asks you about where you or the primary shopper (person who does the most grocery shopping) shopped for groceries in the past year.

A1. Where do you (or primary shopper) usually buy most of your groceries? WRITE THE NAME OF ONE STORE AND TELL US WHERE IT IS LOCATED.

Store Name: ____________________________________________________________________

Nearest Intersection/Street: ___________________________________________________

City/Town: _____________________________________________________________________

A1a. Is the store listed above a … (FILL IN ONLY ONE)

 Large chain grocery store or supermarket (such as Albertsons, Kroger, Publix, Safeway, Giant)

 Discount superstore (such as Wal-Mart, K-Mart, Target)

• Convenience store (such as 7-Eleven or a mini market) or corner store

• Warehouse club store (such as Sam’s Club, BJ’s, Costco)

• Ethnic market

• Natural or organic supermarket/local market (such as Whole Foods)

 Farmers Market/Farm Stand/Co-op

 Home Delivery Service (such as Peapod or Fresh Direct)

• Other, tell us where: ____________________

A1b. How often do you (or primary shopper) shop for food at this store?

 More than once a week

 Once a week

• Once every two weeks

• About once a month or less

A1c. About how many miles do you (or the primary shopper) live from the store where you buy most of your groceries?

 Less than 1 mile

 1 to less than 3 miles

 3 to less than 5 miles

 5 to less than 10 miles

 10 to less than 20 miles

• 20 or more miles away

A1d. About how many miles is your workplace(or the primary shopper’s workplace) from this store?

 Less than 1 mile

 1 to less than 3 miles

 3 to less than 5 miles

 5 to less than 10 miles

 10 to less than 20 miles

• 20 or more miles away

• Not employed

A1e. How do you (or the primary shopper) usually get to this store? (FILL IN ONLY ONE)

 In my (or primary shopper’s) car

 In a car that belongs to someone I (or primary shopper) live with

 In a car that belongs to someone who lives elsewhere

 Walk

• Ride bicycle

• Bus, subway or other public transit

 Taxi or other paid driver

 Someone else delivers groceries

 Some other way – Tell us how __________________

A1f. How much time does it usually take you (or the primary shopper) to get to this store?

 Less than 10 minutes

 10-20 minutes

 21-30 minutes

 More than 30 minutes

A1g. What are the THREE most important reasons why you (or the primary shopper) shop for groceries at this store?

(FILL IN THREE)

 Close to home

 Close to work or school

• Location convenient but not close to home, work, or school

• Affordable price

• Lots of in store promotions

 Variety of products at the store

• Other items besides groceries at store

 Ethnic foods are available at the store

 High quality meat

 Preferred products are always available at the store

 Better or fresher produce than other stores

• Good service

 Store is clean

 Store is familiar to me

 Store hours of operation are convenient for me

 Frequent shopper program or savings card

 Store accepts EBT

 Home delivery option

• Other, tell us why: ____________________

A2. Besides the store identified in A1, do you (or the primary shopper) buy groceries at other stores?

 Yes

 No  GO TO QUESTION A3a

A2a. About how many other stores do you (or the primary shopper) buy groceries at on a regular basis?

 1

 2

 3

 4 or more

A2b. Where else do you (or the primary shopper) go to buy groceries?

(FILL IN ALL THAT APPLY)

 Large chain grocery store or supermarket (such as Albertsons, Kroger, Publix, Safeway, Giant)

 Discount superstore (such as Wal-Mart, K-Mart, Target)

• Convenience store (such as 7-Eleven or mini market) or corner store

• Warehouse club store (such as Sam’s Club, BJ’s, Costco)

• Ethnic market

• Natural or organic supermarket/local market (such as Whole Foods)

 Farmers Market/Farm Stand/Co-op

 Home Delivery Service (such as Peapod or Fresh Direct)

• Other, tell us where: ____________________

A2c. How often do you (or the primary shopper) usually buy groceries at any of the stores referred to in A2a?

 More than once a week

 Once a week

• Once every two weeks

• About once a month or less

A3a. Thinking about ALL the stores where you (or the primary shopper) shop for groceries, please indicate the extent to which a variety (that is, different kinds) of products in these food categories are available to you at these stores?

How much variety is available for …	A wide variety	Some variety	Very little variety	Not available	Don’t know/Don’t buy
Fresh fruits					
Frozen fruits					
Canned fruits					
Fresh vegetables					
Frozen vegetables					
Canned vegetables					
Whole grain products such as brown rice, multi-grain cereal, whole grain pasta					
Lean meat such as 92% or more lean ground beef, skinless chicken breasts, fat free deli meats					
Low fat dairy products such as milk, cheese, yogurt					

A3b. Thinking about ALL the stores where you (or the primary shopper) shop for groceries, how easy is it to afford these foods on your budget?

How easy is it to afford these foods on your budget?	Very Easy	Easy		Difficult	Very Difficult	Don’t know/Don’t eat
Fresh fruits						
Fresh vegetables						
Whole grain products such as brown rice, multi-grain cereal, whole grain pasta						
Lean meat such as 92% or more lean ground beef, skinless chicken breasts, fat free deli meats						

A4. In the past 30 days, about how much money did you/your household spend on food at supermarkets, grocery stores, or other stores that sell food products (including any purchase made with SNAP/formerly known as Food Stamp benefits)?

$___|___|___|

A4a. In the past 30 days, about how much money did you/your household spend on non-food items (such as cleaning or paper products, pet food, cigarettes, or alcoholic beverages) at supermarkets, grocery stores, or other stores that sell food products?

$___|___|___|

A5. What are the THREE most important reasons why you (or the primary shopper) choose the foods you buy? (FILL IN THREE)

 The price

• The brand name

• The nutrition content

• The taste

 Expiration date

• Ease of preparation

 How well the food keeps after it’s bought

 Other, tell us why: _________________________________________

A6. How often do you (or the primary shopper) use the following strategies to buy groceries for yourself/your household?

How often do you …	Always/almost always	Sometimes	Rarely	Never
Make a food budget				
Plan meals and snacks for your household				
Make a shopping list of foods you need to make the meals and snacks for you/your household				
Check store ads for sales				
Shop at stores with the lowest price				
Use manufacturer or store coupons/bonus cards				
Shop for specials				
Buy non-perishables in bulk				
Buy store brand food products				
Choose a brand with the lowest price				
Buy whole fruits and vegetables				
Buy canned or frozen fruits and vegetables to save money				
Shop at more than one store to get the best deals				

SECTION B: NUTRITION KNOWLEDGE

The following questions are about the Federal Government’s nutrition guidelines for Americans

Please indicate the extent to which you agree with the following statements about your/your household’s ability to eat a healthy diet. In this survey, a healthy diet means eating a variety of food from all five food groups (fruits, vegetables, grains, dairy, and protein foods). It also means not eating too much saturated fat, salt, or sugar, and getting the right amount of calories for you.

B1. On most days, I/people in my household eat a healthy diet.

 Strongly Agree

 Agree

 Disagree

 Strongly Disagree

B2. I/People in my household understand the importance of eating healthy to stay healthy

 Strongly Agree

 Agree

 Disagree

 Strongly Disagree

B3. Please tell us if any of the following reasons keep you (or the primary food shopper) from shopping for foods that are part of a healthy diet.

In this survey, a healthy diet means eating a variety of food from all five food groups (fruits, vegetables, grains, dairy, and protein foods). It also means not eating too much saturated fat, salt, or sugar, and getting the right amount of calories for you. (FILL IN ALL THAT APPLY)

 Distance to store

• Transportation

• Store hours

• Affordability (food prices)

• Physical disability

• Amount of time available to shop at the store

• Safety concerns (in and around the stores)

• Other, Challenge is: __________________________________________

• None of the above, I am able to shop for foods that are a part of healthy diet

B4. Please tell us if any of the following reasons keep you (or the primary food shopper) from preparing meals that are part of a healthy diet.

In this survey, healthy diet means eating a wide variety of foods which contain plenty of fiber and are low in fat, salt, and sugar. (FILL IN ALL THAT APPLY)

 Lack of time to prepare meals from scratch

• Lack of equipment (working stove, pots and pans) to prepare food

• Lack of storage to keep cooked or fresh food

• Don’t know how to cook from scratch

• Don’t always know what foods are part of a healthy diet

• Physical disability

• Household members don’t like home cooked meals

• Other, Challenge is: __________________________________________

B5. How familiar are you with the following graphic?

 I have seen it and know a lot about it

 I have seen it and know somewhat about it

 I have seen it but know very little about it

 I have never seen it before  GO TO QUESTION B7

B6. Have you tried to follow the MyPlate information?

 Yes

 No

 I do not know what MyPlate is

B7. How often do you use the Nutrition Facts Panel (example shown on the right) when deciding to buy a food product?  Always  Most of the time  Sometimes  Rarely  Never  GO TO SECTION C  I have not seen the Nutrition Facts Panel on food labels  GO TO SECTION C B8. What nutritional information do you look for on the Nutrition Facts Panel? (FILL IN ALL THAT APPLY)  Nutritional quality of food  Serving size  Calories

SECTION C: PREPARING FOOD AT HOME

When answering questions, please think about your household. By household, we mean people who live with you and with whom you purchase and prepare food.

If you live alone, please answer only for yourself.

C1. The following statements describe people’s attitudes towards cooking, cooking skills, and practices.

Please indicate the extent to which you agree with them when thinking about the person who cooks the most in your household, whether that is you or someone else.

The person who does the most cooking in my household (you or the primary food preparer)…	Strongly agree	Agree	Disagree	Strongly disagree
Prepares healthy meals for people in my household				
Knows how to cook healthy meals				
Usually makes main dishes that require more than 3 ingredients				
Can make a meal out of whatever foods are at home				
Often tries new recipes				
Prepares batch meals that can be eaten throughout the week				
Does not prepare healthy meals because no one in my household likes them				
Does not prepare healthy meals because they do not satisfy hunger				
Usually has basic ingredients for a meal at home				
Usually has basic equipment to prepare a meal at home				
Does not have the time to prepare healthy meals				

C2. When it comes to dinners, would you say that most of the dinners (or the main meal of the day) eaten in your home are… (FILL IN ONLY ONE)

 Cooked from scratch using basic ingredients

 Assembled using readymade ingredients (such as sauces and mixes)

• Convenience foods that are “heat and serve”

• Purchased ready to eat (do not require heating, assembly, or cooking)

C3. On a typical day, how much time do you/primary food preparer in your household spend on cooking dinner (or the main meal of the day)?

• 15 minutes or less

• 16 to 30 minutes

• 31 to 60 minutes

• More than 60 minutes

• I/We don’t prepare meals at home on a typical day.

C4. In the past 7 days, how many home-cooked dinners (or the main meal of the day) did you/the primary food preparer make from scratch, using basic ingredients?

Number of meals

(PLEASE SPECIFY A NUMBER FROM 0 TO 7)

C5. In the past 7 days, how many meals (including breakfast, lunch, and dinner) did you/people in your household get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, convenience stores or from vending machines?

_____ Number of meals

(PLEASE SPECIFY A NUMBER FROM 0 TO 21)

C5a. During the past 7 days, how many of these meals (including breakfast, lunch, and dinner) were from a fast-food or pizza place?

_____ Number of meals that were from fast food or pizza place

(PLEASE SPECIFY A NUMBER FROM 0 TO 21)

C5b. During the past 7 days, how many of these meals (including breakfast, lunch, and dinner) were “ready to eat” foods (such as main dishes, salads, soups, sandwiches) from a grocery store? Please do not include deli meat or cheese you buy for sandwiches or frozen and canned foods.

_____ Number of meals that were “ready to eat” foods

(PLEASE SPECIFY A NUMBER FROM 0 TO 21)

C5c. During the past 7 days, how many of these meals (including breakfast, lunch, and dinner) were frozen meals, frozen main dishes, or frozen pizzas?

______ Number of frozen meals, frozen main dishes, or frozen pizzas

(PLEASE SPECIFY A NUMBER FROM 0 TO 21)

These following questions are about the foods eaten in your household in the past 12 months and whether you were able to afford the foods you need.

C6. Which of these statements best describes the food eaten in your household in the past 12 months?

 Enough of the kinds of food we want to eat

 Enough but not always the kinds of food we want to eat

 Sometimes not enough to eat

 Often not enough to eat

C7. In the last 12 months, we worried whether our food would run out before we got money to buy more. Was that

 Often true

 Sometimes true

 Never true

C8. In the last 12 months, the food that we bought just didn’t last, and we didn’t have money to get more. Was that

 Often true

 Sometimes true

 Never true

C9. In the last 12 months, we couldn’t afford to eat balanced meals. Was that

 Often true

 Sometimes true

• Never true

C10. In the last 12 months, 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, almost every month

 Yes, some months but not every month

 Yes, only 1 or 2 months

 No

C11. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?

 Yes

 No

C12. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?

 Yes

 No

C13. In the last 12 months, did you lose weight because there wasn't enough money for food?

 Yes

 No

C14. In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food?

 Yes, almost every month

 Yes, some months but not every month

 Yes, only 1 or 2 months

 No

The following are several statements that people have made about the food situation of their children. Please answer these questions about the food situation of children living in the household who are under 18 years old. IF YOUR HOUSEHOLD DOES NOT INCLUDE CHILDREN UNDER 18, PLEASE GO TO QUESTION C22.

C15. In the last 12 months, we relied on only a few kinds of low-cost food to feed the children because we were running out of money to buy food.

 Often true

 Sometimes true

 Never true

C16. In the last 12 months, we couldn’t feed the children a balanced meal, because we couldn’t afford that.

 Often true

 Sometimes true

 Never true

C17. In the last 12 months, the children were not eating enough because we just couldn't afford enough food.

 Often true

 Sometimes true

 Never true

C18. In the last 12 months, did you ever cut the size of any of the children's meals because there wasn't enough money for food?

 Yes

 No

C19. In the last 12 months, did any of the children ever skip meals because there wasn't enough money for food?

 Yes, almost every month

 Yes, some months but not every month

 Yes, only 1 or 2 months

 No

C20. In the last 12 months, were the children ever hungry but you just couldn't afford more food?

 Yes

 No

C21. In the last 12 months, did any of the children ever not eat for a whole day because there wasn't enough money for food?

 Yes

• No

C22. In the last 12 months, how often did you/people in your household have to do any of the following things to make your food money go further?

In the last 12 months, how often did you/people in your household have to…	Often	Once in a while	Hardly at all	Never/not an option
Get food you have to replace from family or friends				
Borrow money you have to repay from family or friends				
Carry or increase credit card debt				
Send household members to eat elsewhere				
Send household members to stay elsewhere				
Exchange labor for food				
Buy groceries using money set aside for other purposes				
Get food from a pantry or soup kitchen				
Skip buying medicine or seeking medical care				
Delay paying rent/mortgage				
Delay paying other bills (e.g., utilities, car, credit cards, etc.)				
Sell or pawn household items				
Other, please specify: _________________				

C23. Please tell us which of the following community food options/supports are available in your community (FILL IN ALL THAT APPLY):

• Food bank/ food pantry

• Free meals served at a food kitchen/soup kitchen

• Free meals served at church/school/community center

• Don’t know

• Other places where food is available to those in need, please tell us where: __________________________________________________

• There is no community food support available in my community

SECTION D: HOUSEHOLD FINANCES

When answering the following questions, please think about your household.

By household, we mean people who live with you and with whom you purchase and prepare food. If you live alone, please answer only for yourself.

D1. Who is responsible for day-to-day decisions about money in your household?

 I am

 My spouse/partner

 Joint decision (with partner or other household member)

 Another household member

 Nobody

D2. Which of the following statements best describes budgeting habits in your household? (FILL IN ALL THAT APPLY)

 I/We do not have enough money to have a budget

 I/We do not have the time to make a budget and follow it

 I/We would like to have a monthly budget but don’t know how to make one

 I/We have a budget for monthly bills but not for everyday expenses

 I/We have a monthly budget and I/We use it to plan for all my expenses

D3. Which of the following best describes you/your household’s financial situation?

• All bills are paid on time and there are no debts in collection

• I/We sometimes miss a payment but have no debts in collection

• I/We struggle to pay bills every month but have no debts in collection

• I/We get calls from collectors and struggle to pay bills every month

• I am /We are considering filing for bankruptcy or have filed bankruptcy in the past three years

D4. Do you/your household currently have any bills that are past due?

• Yes

• No

D5. Please rate the extent to which each of the problems below personally concerned you/ your household in the past 12 months.

	Not a problem	Is a mild problem	Is a moderate problem	Is a severe problem
Ability to pay for utilities (heating/cooling/water)				
Ability to pay rent or mortgage				
Getting someone to watch over children or other dependents				
Having reliable, convenient transportation				
Ability to obtain medicines as needed				

SECTION E: YOU AND YOUR HOUSEHOLD

E1. In general, would you say your health is…?

 Excellent

 Very good

 Good

 Fair

• Poor

E2. Have you or anyone in your household been instructed by your doctor to follow a particular diet to address a specific health condition (e.g., diabetes, high blood pressure) IN THE PAST YEAR?

 Yes

 No

E3. Are you male or female?

 Male

 Female

E4. What is your marital status?

 Now married

 Widowed

 Divorced

 Separated

 Never married

E5. How old are you?

 18-29 years old

 30-39 years old

 40-49 years old

 50-59 years old

 60 or older

E6. What language(s) do you usually speak at home? (FILL IN ALL THAT APPLY)

 English

 Spanish

 Other, Please specify: __________________________________________________________

E7. Are you Hispanic or Latino?

 Yes, Hispanic or Latino

 No, Not Hispanic or Latino

E8. Which one or more of the following would you say is your race?

(FILL IN ALL THAT APPLY)

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White

 Other [specify]____________________________

E9. Were you born outside of the United States, Puerto Rico, or other U.S. territories?

 Yes

• No  GO TO QUESTION E10

E9a. How long have you lived in the United States?

 Less than 1 year

 1 to 5 years

 6 to 10 years

 More than 10 years

E10. What is the highest grade or level of school you have completed or the highest degree you have received?

 Less than high school

 High school diploma or GED

 Some college, no degree

 Associate degree: occupational, technical, or vocational program

 Associate degree: academic program

 Bachelor’s degree (example: BA, AB, BS, BBA)

 Master’s degree (example: MA, MS, MEng, MEd, MBA)

 Professional school degree (example: MD, DDS, DVM, JD)

 Doctoral degree (example: PhD, EdD)

E11. Do you live…? (FILL IN ONLY ONE)

 In a place such as home, apartment, or mobile home  GO TO QUESTION E11a

 In someone else’s household  GO TO QUESTION E11b

 In a group care or board or care facility or shelter  GO TO QUESTION E11b

 Other  GO TO QUESTION E11b

E11a. Is the place where you live … (FILL IN ONLY ONE)

 Owned by you or someone in your household with a mortgage or loan

 Owned by you or someone in your household free and clear (without a mortgage or loan)

 Rented

 Rented to buy

 Occupied without paying rent

E11b. How many rooms are in this home, including kitchen but not the bathrooms?

|___|___| rooms

E11c. Does the place where you live have a kitchen?

 Yes

 No  GO TO QUESTION E11e

E11d. Do you have basic cooking equipment, such as pots and pans, utensils, and plates, in your kitchen?

 Yes

 No

E11e. Does the place where you live have a stove or something to cook on?

 Yes

 No

E11f. Does the place where you live have a functioning refrigerator?

 Yes

 No

E11g. Does the place where you live have a functioning microwave?

 Yes

 No

E12. Including you, how many people currently live in your household? By household, we mean the people who share food and income with you. Please do not include people in your home who your SNAP/Food Stamp benefits and other income do not support.

|___|___|

E12a. How many of these are children 5-17 years old?

|___|___| number of children

E12b. How many of these are children under 5 years of age?

|___|___| number of children

E12c. How many are adults over 60 years?

|___|___| number of adults over 60

E13. In the last 12 months, has there been a change in the number of people living in your household?

 Yes

• No  GO to QUESTION E14

E13a. What caused the change? (FILL IN ALL THAT APPLY)

 Birth of child

 New step, foster, or adopted child

 Marriage/New partner

 Separation or divorce

 Death of a household member

 Boarder moving in

 Family/boarder moving out

 Other, Please specify: ______________________________________________

E14. Do you or anyone in your household … (FILL IN ALL THAT APPLY)

 Have serious difficulty hearing or is deaf?

 Have difficulty seeing even when wearing glasses?

 Have a physical, mental, or emotional condition causing difficulty concentrating?

 Suffer from depression?

 Have serious difficulty walking or climbing stairs?

 Have difficulty dressing or bathing?

 Have a physical, mental, or emotional condition causing difficulty doing errands such as visiting a doctor or shopping?

 None of the above

E15. In the past 12 months, did any children who live in your household get free or reduced price lunch from the National School Lunch Program?

 Yes

 No

E16. In the past 12 months, did any children who live in your household get free or reduced price breakfast from the School Breakfast Program?

 Yes

 No

E17. In the past 12 months, did any children who live in your household get free or reduced price lunch from the Summer Food Service Program?

 Yes

 No

E18. In the past 12 months, did any children who live in your household go to a Head Start program or a childcare program where they got free meals?

 Yes

 No

E19. In the past 12 months, did you or anyone who lives in your household get help from WIC, that is the Women, Infants, and Children Program?

 Yes

 No

E20. In the past 12 months, did you or anyone who lives in your household go to a community program or senior center to eat prepared meals?

 Yes

 No

E21. In the past 12 months, did you or anyone who lives in your household receive any meals delivered to your home from community programs, “Meals on Wheels” or any other programs?

 Yes

 No

E22. In the past 12 months, did you or anyone who lives in your household receive financial incentives (such as bonus bucks) to shop at farmers markets?

 Yes

 No

E23. In the past 12 months, did you or anyone who lives in your household get any other type of food assistance, such as from churches, food banks, food pantries, or other organizations?

 Yes

 No

E24. In the past 12 months, did you or anyone who lives in your household get financial assistance to pay rent (e.g., Housing Choice Voucher)?

 Yes

 No

E25. In the past 12 months, did you or anyone who lives in your household receive assistance from the Home Energy Assistance Program to pay electric or gas utility bills?

 Yes

 No

E26. In the past 12 months, did you or any other adult in your household receive employment and training services to get a job, new skills, or school degree?

 Yes

 No

E27. Do you or anyone in your household currently get SNAP benefits? This includes any SNAP benefits, even if the amount is small and even if benefits are received on behalf of children in the household.

 Yes

 No  GO TO QUESTION E29

E27a. During the past 12 months, for how many months did you get SNAP benefits?

|___|___| months

E27b. On what date were SNAP benefits last put on your EBT card?

|___|___| - |___|___| - |___|___|___|___|

MONTH DAY YEAR

E27c. Last month, how much did you receive in SNAP benefits?

$ |___|___|___|

E28. How many weeks do your monthly SNAP benefits usually last?

• 1 week or less

• 2 weeks

• 3 weeks

• 4 weeks

• More than 4 weeks

E29. Which of the following best describes your current work situation?

(FILL IN ONLY ONE)

 Employed for wages

 Self-employed

 Out of work for more than 1 year

 Out of work for less than 1 year

 A homemaker

 A student

 Retired

 Unable to work because of disability

 Other, Please specify: ______________________________________________

E30. Not including yourself, how many adults age 18 and older in the household were employed last week?

|___|___| number of adults

 Does not apply to me, I live alone

E31. Have you or anyone in your household had a change in employment or a change in pay or hours worked from a job in the past 6 months?

 Yes

 No  GO TO QUESTION E32

E31a. Was that change you/anyone in your household experienced in the past 6 months due to (FILL IN ALL THAT APPLY)

 Getting a job

 Losing a job

 Increase in pay or hours

 Decrease in pay or hours

 Other [specify] _______________________________

E32. 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, SNAP benefits, WIC benefits, help from relatives, and so forth). Please round to the nearest dollar amount.

$|___|___|___|___|___|___|___|

E33. Please indicate whether you or anyone in your household received income in the last 12 months from any of the following: (FILL IN ALL THAT APPLY)

 Wages, salary, commissions, bonuses, or tips from all jobs

 Self-employment income from own nonfarm business or 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 (SSI)

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

 Retirement, survivor, or disability pensions

 Veterans’ (VA) payments

 Unemployment compensation

 Child support

 Alimony

 Any other sources of income received regularly, Please specify: ______________________________________________

THANK YOU FOR COMPLETING THIS SURVEY.

PLEASE RETURN THE SURVEY IN THE POSTAGE-PAID ENVELOPE PROVIDED TO YOU. IF THE ENVELOPE IS MISSING, PLEASE SEND TO: FOOD AND YOUR HOUSEHOLD SURVEY, 1600 RESEARCH BLVD, ROCKVILLE, MD 20850.