Screener Instrument

Appendix D: Screener Questionnaire for Participant Recruitment

The U.S. Department of Agriculture is planning a survey to gather information on how and where Americans obtain food. It will help the government make policies intended to ensure that all Americans can afford to get healthy food. We are recruiting participants to help evaluate a data entry instrument. Thank you for your interest in participating in this study. Due to the nature of this study, only certain individuals are eligible to participate. To determine if you are eligible, I would like to ask you a few questions. Please answer each question honestly.

Privacy Act Statement

 

Authority for the collection of this pilot test is provided under 7 U.S.C. Sections 3171 and 2026 (a)(1). The U.S. Census Bureau is conducting this pilot test on behalf of the U.S. Department of Agriculture (USDA) under the authority of 13 U.S.C. Section 8(b).

The purpose of this study is to evaluate respondents’ effectiveness of, efficiency in, and satisfaction with using the Qualtrics-based online instrument to enroll in the FoodAPS-2 Pilot Test survey, report food acquisition, and complete the post-data-reporting debriefing. Personally Identifiable Information (PII) collected is age, gender, race, and race/ethnicity.

Disclosure of the information provided to us is permitted under the Privacy Act of 1974 (5 U.S.C. § 552a) and may be shared with other Census Bureau staff for work-related purposes. Disclosure of this information is also subject to all the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/Census- COMMERCE/Census-3, Demographic Survey Collection (Census Bureau Sampling Frame) and authorized employees from the U.S. Department of Agriculture (USDA).

Census Bureau staff have received training on privacy and confidentiality policies and practices. Access to PII/BII is restricted to authorized personnel only. Access to PII/BII is being monitored, tracked, or recorded on Census Bureau IT systems.

Your participation is voluntary, however without participation, the Census Bureau will not have enough information to determine if the survey questions and functionality of the instrument is adaptable for all possible participant groups. 

1. Are you the person who does most of the shopping for food in your family?

Yes

No (STOP RECRUITMENT)

2. Do you currently own a smartphone?

Yes

No (STOP RECRUITMENT)

3. What smartphone are you using?

iPhone

Android phone

Other (STOP RECRUITMENT)

4. How long have you been using a smartphone on daily basis? (Check one of the following)

Less than 1 year (STOP RECRUITMENT)

1 year or more

5. Would you be willing to use your smartphone for this study?

Yes

No (STOP RECRUITMENT)

7. The study will require you to use your own wireless data service when you are not on Wi-Fi.

Would you be OK with that?

Yes

No (STOP RECRUITMENT)

10. Do you have an internet and Wi-Fi service at home (e.g., Verizon Fios)?

Yes

No (STOP RECRUITMENT)

12. In order to conduct the study, we need you to install Microsoft Teams, secure audio-video communication software, on your smartphone. It is a simple task and will not interfere with your use of the smartphone. Would you be OK with it?

Yes

No (STOP RECRUITMENT)

13. How many adults, who are 18 or older, live in your household (including you)?

[#]

14. How many children, who are attending a K-12 school and between 14 and 17 years old, live in your household?

[#]

14a. One aspect of this study is to explore how school age children would report the food they get at school. If they qualify, do we have your authorization to invite [one of] your child[ren] to participate in the study?

Yes

No

15. How many children, who are attending a K-12 school and under 14 years old, live in your household?

[#]

16. Is your household currently receiving food assistance, such as WIC or SNAP? (WIC stands for the Special Supplemental Food Program for Women, Infants, and Children. This program provides food assistance and nutritional screening to low-income pregnant and postpartum women and their infants, as well as to low-income children up to age 5. SNAP stands for Supplemental Nutrition Assistance Program, also known as the Food Stamp Program. SNAP benefits are provided on a food stamp benefit card/EBT card)

[SNAP/WIC/Both/No]