H:\PROJECT\8305\012\Ques\wn-long.q7--GREEN QC: CODER: _______________ DATE: _______________

(REV - 1/21/98) 12/16/99 11:19 AM

OMB No.: 0584-0486

Expiration Date: 11/98

WORKING NONPARTICIPANT

LONG INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\wn-long.q7 2 (REV--1/21/98) 12/16/99 11:19 AM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Working Nonparticipant--Long

A. HOUSEHOLD COMPOSITION

A1. Please tell me the first name or initials of each person who currently lives in your

household starting with you. By household I mean people who live with you and

share food with you.

PROBE: Include any persons who live with you more than half time.

A2. How is (NAME) related to you? ENTER CODE BELOW.

A3. How old (are you/is NAME)? PROBE: Your best estimate is fine.

Person

Number First Name or Initials Relationship Age

A1. A2. A3.

1. ______________________ SELF

|___|___|

DON’T KNOW ......... -1

2. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

3. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

4. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

5. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

6. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

7. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

8. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

9. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

10. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 3 (REV--1/21/98) 12/16/99 11:19 AM

RELATIONSHIP CODES

01 MALE SPOUSE/PARTNER 06 GRANDMOTHER 11 OTHER MALE RELATIVE

02 FEMALE SPOUSE/PARTNER 07 SON/STEPSON OR NONRELATIVE

03 FATHER/STEPFATHER 08 DAUGHTER/STEPDAUGHTER 12 OTHER FEMALE RELATIVE

04 MOTHER/STEPMOTHER 09 BROTHER/STEPBROTHER OR NONRELATIVE

05 GRANDFATHER 10 SISTER/STEPSISTER
H:\PROJECT\8305\012\Ques\wn-long.q7 4 (REV--1/21/98) 12/16/99 11:19 AM

A4. I’ve recorded the following names (READ NAMES FROM A1). Is there anyone

else such as babies or small children? Anyone who usually lives with you but is

now away from home, or, anyone else staying here?

YES ............................. 01 ! GO BACK AND

CORRECT A1-A3

NO .............................. 00
H:\PROJECT\8305\012\Ques\wn-long.q7 5 (REV--1/21/98) 12/16/99 11:19 AM

B. KNOWLEDGE OF THE FSP

B0. Before we talked to you about this survey, had you heard of food stamps or the

Food Stamp Program?

YES ............................. 01

NO .............................. 00 ! SKIP TO FO, PAGE 29

B1. As far as you know, did your family ever receive food stamp benefits when you

were a child?

YES ............................. 01

NO .............................. 00

B2. As far as you know, do any of your relatives, friends, neighbors, or co-workers

currently receive food stamp benefits?

YES ............................. 01

NO .............................. 00

DON’T KNOW ..................... -1

B3.-

B8. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\wn-long.q7 6 (REV--1/21/98) 12/16/99 11:19 AM

C. FSP PARTICIPATION HISTORY

C1. Have you received food stamp benefits in the past 3 years?

YES ............................. 01 ! SKIP TO C2a

NO .............................. 00

C2. Over the course of your adult life have you ever received food stamp benefits?

YES ............................. 01 

 SKIP TO D1

NO .............................. 00

C2a. Did you receive food stamp benefits for more than 3 months since February 1,

1997?

YES ............................. 01

NO .............................. 00

DON’T KNOW ..................... -1

C3. When was the last time you received food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

C3a. INTERVIEWER: IS DATE MORE THAN THREE YEARS AGO?

YES ................................. 01 ! SKIP TO D1

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 7 (REV--1/21/98) 12/16/99 11:19 AM

C4. How did you get your food stamp benefits in (DATE FROM C3)? Did you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ........................... 01

EBT CARD ........................... 02

C4a. What was the amount of food stamp benefits you received in (DATE FROM C3)?

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

C5. Did you stop receiving food stamp benefits in (DATE FROM C3) because you

were notified that you were not eligible?

YES ................................. 01 ! SKIP TO C13a

NO .................................. 00
H:\PROJECT\8305\012\Ques\wn-long.q7 8 (REV--1/21/98) 12/16/99 11:19 AM

C6. Why did you stop participating in the food stamp program in (DATE FROM C3)? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

NOT WORTH THE EFFORT FOR

THE AMOUNT OF BENEFITS ............ 01

NO LONGER NEEDED FOOD STAMP

BENEFITS ............................ 02

EMBARRASSED USING FOOD STAMP

BENEFITS ............................ 03

THOUGHT NO LONGER ELIGIBLE ........ 04

THOUGHT SITUATION WOULD

IMPROVE ............................ 05

HARD TO GET TO FOOD STAMP OFFICE . . 06

PROCESS OF RECEIVING FOOD

STAMP BENEFITS IS TOO LONG

OR COMPLICATED .................... 07

HAD TO ANSWER TOO MANY

PERSONAL QUESTIONS ................ 08

FAMILY MEMBERS DISAPPROVED

OF MY/OUR RECEIVING FOOD

STAMP BENEFITS ..................... 09

DO NOT LIKE TO RELY ON

GOVERNMENT ASSISTANCE ............ 10

OTHER PEOPLE NEEDED THEM MORE ... 11

NOT TREATED WELL BY STAFF ......... 12

OFFICE IS VERY UNPLEASANT .......... 13

OFFICE IN AN UNSAFE

NEIGHBORHOOD ..................... 14

OTHER (SPECIFY) ..................... 15

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 9 (REV--1/21/98) 12/16/99 11:19 AM

C7.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO C13c

REFUSED ............................ -3

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

SKIP TO C13c
H:\PROJECT\8305\012\Ques\wn-long.q7 10 (REV--1/21/98) 12/16/99 11:19 AM

C13a. Why were you found ineligible? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

_____________________________________

 |__|__| |__|__|

DON’T KNOW ......................... -1

C13b. NO QUESTION THIS VERSION.

C13c. When you received food stamps in the past three years, did you ever do things

so that people would not find out you received food stamp benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ................................. 01

NO .................................. 00
H:\PROJECT\8305\012\Ques\wn-long.q7 11 (REV--1/21/98) 12/16/99 11:19 AM

C14. Now I’m going to ask you some questions about your experiences with food

stamp benefits over the past three years.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in

stores, were you sometimes treated

disrespectfully by either employees or other

customers? ........................ 01 00

b. Were you embarrassed to use food stamp

benefits? .......................... 01 00

c. Did you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Did you feel that you really needed food

stamp benefits to make it through the

month? ............................ 01 00

e. Did you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Did you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Did food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Did you experience other difficulties with food stamp benefits that you have not

already mentioned? Please do not include any difficulties you had applying, we

will ask about this later.

YES ................................. 01

NO .................................. 00 ! SKIP TO D1
H:\PROJECT\8305\012\Ques\wn-long.q7 12 (REV--1/21/98) 12/16/99 11:19 AM

C16. Please describe those difficulties. RECORD VERBATIM

|__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 13 (REV--1/21/98) 12/16/99 11:19 AM

D. HISTORY OF APPLICATIONS

D1. Have you applied for food stamp benefits in the past 3 years? By applied I mean

have you at least completed a new application form?

YES ................................. 01

NO .................................. 00 

 SKIP TO D14

DON’T KNOW ......................... -1

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ................................. 01 ! SKIP TO D4c

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 14 (REV--1/21/98) 12/16/99 11:19 AM

D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ........................ 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . . 05

 

 |__|__| |__|__|

D4c. Did you apply yourself or did an authorized representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ................ 01

AT SSI OFFICE ......................... 02

AT A SENIOR CENTER .................. 03 SKIP TO D4f

AT A HOSPITAL ........................ 04

AT A HOUSING COMPLEX ............... 05

SOMEWHERE ELSE (SPECIFY) ........... 06

 

 |__|__| |__|__|

AT HOME ............................. 07
H:\PROJECT\8305\012\Ques\wn-long.q7 15 (REV--1/21/98) 12/16/99 11:19 AM

D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ........................ 01

VISIT BY CASEWORKER ................ 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

DOESN’T WORK ....................... -4

D4g. The last time you applied, did you have a lot of help with the application?

YES .................................. 01

NO ................................... 00 

SKIP TO D5

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 16 (REV--1/21/98) 12/16/99 11:19 AM

D4h. What type of help did you receive? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D4i. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 17 (REV--1/21/98) 12/16/99 11:19 AM

D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

 |__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\wn-long.q7 18 (REV--1/21/98) 12/16/99 11:19 AM

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ................................. 01

NO .................................. 00 ! SKIP TO D8
H:\PROJECT\8305\012\Ques\wn-long.q7 19 (REV--1/21/98) 12/16/99 11:19 AM

D7b. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO D10

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\wn-long.q7 20 (REV--1/21/98) 12/16/99 11:19 AM

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO 

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO FS

OFFICE .............................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 21 (REV--1/21/98) 12/16/99 11:19 AM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................ 01

NO ................................. 00 

 SKIP TO D12

DON’T KNOW ........................ -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 22 (REV--1/21/98) 12/16/99 11:19 AM

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them but did not use any

of them.

YES ................................. 01

NO .................................. 00 

 SKIP TO E1

DON’T KNOW ......................... -1

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD

STAMP BENEFITS ............................ 01

NOT TREATED WELL IN FOOD STORES .......... 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ...................... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS ......... 04

NOT TREATED WELL BY OFFICE/

PROGRAM .................................. 05

TOO HARD TO PICK UP COUPONS/

STAMPS .................................... 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN ................................. 07

BENEFIT AMOUNT WAS TOO SMALL ............ 08

DID NOT NEED FOOD STAMPS ................. 09

OTHER (SPECIFY) ............................ 10

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 23 (REV--1/21/98) 12/16/99 11:19 AM

GO TO E1

D14. Have you contacted the food stamp office to ask about food stamp benefits in the

past 3 years?

YES ................................. 01

NO .................................. 00 ! SKIP TO E1

D15. When was the last time you contacted the food stamp office to ask about food

stamp benefits?

|___|___| 19|___|___|

 MONTH YEAR

D16. Which of the following reasons led you to ask about food stamp benefits in (DATE

FROM D15)?

YES NO

a. Your household income fell? .................................. 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ................. 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? ............... 01 00

f. You couldn’t get as much food as you needed from family, friends,

government programs, or other sources (such as food banks)? ........ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food stamp benefits? 01 00

j. Some other reason? (SPECIFY) ...............................

 |__|__| |__|__|

01 00
H:\PROJECT\8305\012\Ques\wn-long.q7 24 (REV--1/21/98) 12/16/99 11:19 AM

D16a.-

D16b. NO QUESTIONS THIS VERSION.

D16c. Why didn’t you complete an application form at that time? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO FOOD

STAMP OFFICE ....................... 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|

D17.-

D21. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\wn-long.q7 25 (REV--1/21/98) 12/16/99 11:19 AM

E. NON-PARTICIPATION

Now I would like to talk to you about the reasons you currently do not use food stamps.

E1. E2. E4.

Is this an important reason

you don’t use food stamp

benefits?

YES NO KNOW YES NO KNOW REASON

DON’T DON’T IMPORTANT

MOST

a. Do you know where to go or who to

contact to apply for food stamp SKIP 

benefits? ...................... 01 !TO E1b 00 -1 01 00 -1 01

b. Do you think you are currently eligible SKIP 

for food stamp benefits? .......... 01 !TO E1c 00 -1 01 00 -1 02

c. Do you think it would be hard to get SKIP SKIP 

to the food stamp office? .......... 01 00 ! TO E1d -1 !TO E1d 01 00 -1 03

d. Do you think the application process SKIP SKIP 

is too long and complicated? ....... 01 00 ! TO E1e -1 !TO E1e 01 00 -1 04

e. Do you think you would have to

answer questions that are too

personal when applying for food SKIP SKIP 

stamp benefits? ................. 01 00 ! TO E1f -1 ! TO E1f 01 00 -1 05

f. Do you think you would feel

embarrassed applying for SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1g -1 !TO E1g 01 00 -1 06

g. Do you think you would be eligible for

only a small amount of food stamp SKIP SKIP 

benefits? ...................... 01 00 ! TO E1h -1 !TO E1h 01 00 -1 07

h. Can you get by on your own without SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1i -1 ! TO E1i 01 00 -1 08

i. Do you feel that others need food SKIP SKIP 

stamp benefits more than you do? . . 01 00 ! TO E1j -1 ! TO E1j 01 00 -1 09

j. Would you feel embarrassed using SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1k -1 !TO E1k 01 00 -1 10

k. Would you dislike relying on SKIP SKIP 

government assistance? .......... 01 00 ! TO E1l -1 ! TO E1l 01 00 -1 11

l. Would other family members or

friends discourage you from using SKIP SKIP 

food stamp benefits? ............. 01 00 !TO E1m -1 !TO E1m 01 00 -1 12

m. Do you think that staff at the food

stamp office would treat you SKIP SKIP 

disrespectfully? ................. 01 00 ! TO E1n -1 !TO E1n 01 00 -1 13

n. Do you think that the food stamp

office would be very unpleasant or SKIP SKIP 

you would not be safe? ........... 01 00 ! TO E1o -1 !TO E1o 01 00 -1 14

o. Do you think your need for food SKIP SKIP 

stamp benefits is only temporary? ... 01 00 ! TO E1p -1 !TO E1p 01 00 -1 15
H:\PROJECT\8305\012\Ques\wn-long.q7 26 (REV--1/21/98) 12/16/99 11:19 AM

p. Are there other important reasons

why you do not use food stamp SKIP SKIP

benefits that we have not just 01 00 ! TO E3 -1 ! TO E3 01 00 -1 16

mentioned? ....................

RECORD VERBATIM BELOW:

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\wn-long.q7 27 (REV--1/21/98) 12/16/99 11:19 AM

E3. INTERVIEWER: HOW MANY “YESES” ARE CIRCLED IN QUESTION E2?

NONE ................................ 00 

SKIP TO E5

ONE ................................. 01

MORE THAN ONE ...................... 02

E4. Of all the reasons you gave (READ IMPORTANT REASONS FROM E2 IF

NECESSARY), what is the most important reason you do not currently use food

stamp benefits? RECORD IN COLUMN MARKED E4.

E5. INTERVIEWER: WAS THE RESPONSE TO E1b “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E7

E6. You said you think you are currently eligible for food stamp benefits. How much

in food stamp benefits do you think you would qualify for each month? Your best

estimate is fine.

CIRCLE ONE RESPONSE

$10 OR LESS ......................... 01

BETWEEN $11 AND $25 ................ 02

BETWEEN $26 AND $50 ................ 03

BETWEEN $51 AND $100 ............... 04

BETWEEN $101 AND $150 .............. 05

BETWEEN $151 AND $200 .............. 06

BETWEEN $201 AND $300 .............. 07

MORE THAN $300 ..................... 08

DON’T KNOW ......................... -1

GO TO E9
H:\PROJECT\8305\012\Ques\wn-long.q7 28 (REV--1/21/98) 12/16/99 11:19 AM

E7. You said you think you are not currently eligible for food stamp benefits. Why do

you think that you are not eligible to receive food stamp benefits? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DO NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

E8. Do you think you are currently ineligible because you were told by someone at

the food stamp office that you are ineligible?

YES ................................. 01

NO .................................. 00 ! SKIP TO E8b

E8a. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN THE LAST MONTH .............. 01

WITHIN THE LAST 3 MONTHS ........... 02

WITHIN THE LAST YEAR ............... 03

MORE THAN ONE YEAR AGO ........... 04

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 29 (REV--1/21/98) 12/16/99 11:19 AM

E8b. Were you told by someone at another program that you are ineligible for food 

stamp benefits?

YES ................................. 01 ! SKIP TO E9

NO .................................. 00

DON’T KNOW ......................... -1

E8c. Do you think you are ineligible because you know someone like you who is

ineligible?

YES ................................. 01

NO .................................. 00

E9. INTERVIEWER: WAS THE RESPONSE TO E1c “YES”?

YES ................................. 01

NO .................................. 00 ! SKIP TO E11

E10. You said you think it would be hard to get to the food stamp office. Is this . . .

YES NO

a. Because it is difficult or expensive to get

transportation? ................................... 01 00

b. Because of difficulties you have getting around? ......... 01 00

c. Because of difficulties you would have taking time

off work? ........................................ 01 00

d. Because you would lose pay going to the

food stamp office? ................................ 01 00

e. Because you would have to pay for someone

to take care of someone in your home? ................ 01 00

f. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ...............................

 |__|__| |__|__|

01 00
H:\PROJECT\8305\012\Ques\wn-long.q7 30 (REV--1/21/98) 12/16/99 11:19 AM

E11. INTERVIEWER: WAS THE RESPONSE TO E1d “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12. You think the application process would be too long and complicated.

Is this . . .

YES NO

a. Because you think you would have to wait a long time

to be served? .................................... 01 00

PROBE: A long time from your point of view.

b. Because you think the application form is too long and

complicated? ..................................... 01 00

c. Because you think it would be difficult to get all the necessary

paperwork? ...................................... 01 00

d. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ...............................

 |__|__| |__|__|

01 00

E12a. INTERVIEWER: WAS THE RESPONSE TO PART “a” OF E12 “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12b. You said you would have to wait a long time to be served. How long do you think

you would have to wait? Would it be . . .

15 minutes or less? ...................... 01

16 to 30 minutes? ....................... 02

31 minutes to one hour? .................. 03

Or, more than one hour? .................. 04

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 31 (REV--1/21/98) 12/16/99 11:19 AM

E13. INTERVIEWER: WAS THE RESPONSE TO E1e “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E15

E14. You said you would have to answer questions that were too personal. What type

of questions do you feel are too personal?

CIRCLE ALL THAT APPLY

WHO LIVES IN HOUSEHOLD ............. 01

CITIZENSHIP .......................... 02

DISABILITIES .......................... 03

RESOURCES/ASSETS .................. 04

INCOME .............................. 05

MEDICAL EXPENSES ................... 06

DEPENDENT-CARE EXPENSES ........... 07

SHELTER EXPENSES ................... 08

CHILD-SUPPORT PAYMENTS ............ 09

OTHER (SPECIFY) ...................... 10

 

 |__|__| |__|__|

E15. INTERVIEWER: WAS THE RESPONSE TO E1g “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E17

E16. You said you think you are eligible for only a small amount of food stamp

benefits.
H:\PROJECT\8305\012\Ques\wn-long.q7 32 (REV--1/21/98) 12/16/99 11:19 AM

E16a. Were you told by someone at a food stamp office that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01

NO ................................ 00 

 SKIP TO E16c

DON’T KNOW ....................... -1

E16b. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN LAST MONTH ................ 01

WITHIN LAST 3 MONTHS ............. 02

WITHIN THE LAST YEAR ............. 03

MORE THAN ONE YEAR AGO ......... 04

DON’T KNOW ....................... -1

GO TO E17

E16c. Were you told by someone at another program that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01 ! SKIP TO E17

NO ................................ 00

DON’T KNOW ....................... -1

E16d. Do you think that you would receive only a small amount of benefits because you

know someone like you who receives only a small amount of benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 33 (REV--1/21/98) 12/16/99 11:19 AM

E17. INTERVIEWER: WAS THE RESPONSE TO E1n “YES”?

YES ............................... 01

NO ................................ 00 ! SKIP TO E19

E18. You thought the food stamp office would be very unpleasant or you would not be

safe? Is this . . .

YES NO

a. Because the inside of the building would be unpleasant? 01 00

b. Because you wouldn’t like waiting with the other

applicants? ................................... 01 00

c. Because the office would be in an unsafe neighborhood? 01 00

d. Because of something else? (SPECIFY) ........... 01 00

 |__|__| |__|__|

E19. Do you agree with the statement made by some people that “its OK to receive

food stamp benefits if you pay taxes”?

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\wn-long.q7 34 (REV--1/21/98) 12/16/99 11:19 AM

F. RECEIPT OF FOOD ASSISTANCE

F0. INTERVIEWER: CHECK QUESTION A3. IS ANYONE IN THIS

HOUSEHOLD AGE 60 OR OLDER?

YES ............................... .01

NO ................................ .00 ! SKIP TO F1a

F1. During the past 12 months, did (you/anyone in the household) ever receive free

or reduced-cost meals for the elderly either at a facility or delivered to your

home?

PROBE: By facility we mean places such as a senior center or community

center or some other special place with a meal program.

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

F1a. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ............................... 01

NO CHILDREN ...................... 00 ! SKIP TO F5

F2. During the past 12 months, did any children in the household ever receive free or

reduced-cost meals at a day-care or Head Start program?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

CHILD/CHILDREN DO NOT ATTEND

DAY CARE PROGRAM ............... -4
H:\PROJECT\8305\012\Ques\wn-long.q7 35 (REV--1/21/98) 12/16/99 11:19 AM

F3. Not counting meals at Head Start or daycare programs, during the past 12

months, did any children in the household ever receive free or reduced-cost

lunches at school?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

CHILD/CHILDREN DO NOT

ATTEND SCHOOL ................... -4! SKIP TO F5

F4. During the past 12 months, did any children in the household ever receive free or

reduced-cost breakfasts at school?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

F5. INTERVIEWER: CHECK QUESTION A3. IS ANYONE IN THIS

HOUSEHOLD EITHER UNDER AGE 6 OR A WOMAN

UNDER 45 YEARS OF AGE?

YES ............................... 01

NO ................................ 00 ! SKIP TO F7

F6. During the past 12 months, did (you/anyone in the household) ever get food

through the WIC program?

PROBE: By WIC we mean the U.S. Department of Agriculture’s Special

Supplemental Nutrition Program for Women, Infants, and Children,

which provides food packages to women, infants, and young children.

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 36 (REV--1/21/98) 12/16/99 11:19 AM

(SPECIFY PROGRAM):

 

 |__|__| |__|__|

F7. During the past 12 months, did (you/anyone in the household) ever get food, or

vouchers to buy food, from any (other) kind of program?

YES ............................. 01

NO .............................. 00

DON’T KNOW ..................... -1

F8. In the last 12 months, did you (or other adults in your household) ever get food or

borrow money for food from friends or relatives?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F9. In the last 12 months, did you (or other adults in your household) ever get

emergency food from a church, a food pantry, or food bank?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F10. In the last 12 months, did you (or other adults in your household) ever eat any

meals at a soup kitchen?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 37 (REV--1/21/98) 12/16/99 11:19 AM

Where?

 |__|__| |__|__|

F10a. In the last 12 months, did you (or other adults in the household) ever receive free

or reduced-price meals at work?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F11. Some people are able to get food from their own garden or farm, or from hunting

or fishing. During the last 12 months, did you (anyone in the household) ever get

food from . . .

YES NO

a. Your own vegetable garden? ............................ 01 00 

b. Meat, poultry, or eggs from animals you raise? .............. 01 00 

c. Meat or fish from hunting or fishing? ...................... 01 00 

F11a. In the last 12 months, did you (or other adults in your household) ever get free

food from any source we haven’t already mentioned?

PROBE: Please include any free meals or groceries that you receive from any

person or source that we haven’t already mentioned

YES ................................. 01

NO .................................. 00

F12. Are you uncomfortable getting food from family, friends, charities, or other

programs?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 38 (REV--1/21/98) 12/16/99 11:19 AM

INTERVIEWER: IF RESPONSE CODE IS FOLLOWED BY AN ASTERISK (*),

CIRCLE THE QUESTION NUMBER.

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G2. “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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G3. “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or

never true for (you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 39 (REV--1/21/98) 12/16/99 11:19 AM

G4. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G8

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G6. “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we)

couldn’t afford that.” Was that often, sometimes, or never true for (you/your

household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 40 (REV--1/21/98) 12/16/99 11:19 AM

G7. “(My/Our child was/The children were) not eating enough because (I/we) just

couldn’t afford enough food.” Was that often, sometimes, or never true for

(you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G8. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

33 AND 34? IS THE RESPONSE TO G1, G2, G3, G5, OR G6 “OFTEN TRUE”

(01) OR “SOMETIMES TRUE” (02)?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G10

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 41 (REV--1/21/98) 12/16/99 11:19 AM

G10. In the last 12 months, did you ever eat less than you felt you should because there

wasn’t enough money to buy food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G11. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t

afford enough food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G12. In the last 12 months, did you lose weight because you didn’t have enough

money for food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01 *

NO .................................. 00 

 SKIP TO G14

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 42 (REV--1/21/98) 12/16/99 11:19 AM

G13a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G14. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G15. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

35 AND 36? IS THE RESPONSE TO G7 “OFTEN TRUE” (01) OR

“SOMETIMES TRUE” (02) OR IS THERE A “YES” RESPONSE TO G11, G12 OR

G13?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 43 (REV--1/21/98) 12/16/99 11:19 AM

G17. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals

because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 SKIP TO G18

DON’T KNOW ......................... -1

G17a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G18. In the last 12 months, (was your child/were the children) ever hungry but you just

couldn’t afford more food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G19. In the last 12 months, did (your child/any of the children) ever not eat for a whole

day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 44 (REV - 1/21/98) 12/16/99 11:19 AM

H. EMPLOYMENT HISTORY

H1. Including yourself, which people in your household work at a job for pay? RECORD NAMES AT H1.

NONE .................................. 00 ! SKIP TO J1, PAGE 43

HOUSEHOLD NAMES RECORDED BELOW ... 01

H2. How many hours per week (does NAME/do you)usually work for pay? RECORD BELOW OPPOSITE

PERSONS NAME. PROBE: Your best estimate would be fine.

INTERVIEWER: IF RESPONDENT UNABLE TO TELL YOU USUAL HOURS WORKED PER

WEEK, ASK “HOW MANY HOURS DID YOU WORK LAST WEEK OR DURING

THE MOST RECENT WEEK YOU WORKED IF YOU DID NOT WORK LAST

WEEK?”

H3. How much (does NAME/do you) earn on this job, before taxes and any other deductions are taken out?

RECORD BELOW FOR EACH PERSON.

INTERVIEWER: IF RESPONDENT RECEIVES TIPS AS PART OF EARNINGS, ASK

RESPONDENT TO REPORT WHAT HE OR SHE EARNED LAST WEEK (OR

MOST RECENT WEEK WORKED IF NOT LAST WEEK) INCLUDING TIPS, AND

RECORD AS “SALARY PER WEEK.”

PROBE: What is (NAME’S/YOUR) gross pay?

H1 H2 H3

Name Hours Hourly OR Salary Per Salary Basis

Per Week Wage

1 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

2 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

3 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

4 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
H:\PROJECT\8305\012\Ques\wn-long.q7 45 (REV - 1/21/98) 12/16/99 11:19 AM

5 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
H:\PROJECT\8305\012\Ques\wn-long.q7 46 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

H4. INTERVIEWER: LOOK AT QUESTIONS H1 AND H2. SELECT PERSON

WHO WORKS GREATEST NUMBER OF HOURS PER

WEEK.

NAME:_____________________________________

CODER: PERSON # FROM A1: |___|___|

H5. Now I’m going to ask you some questions about (your/NAME’S) job.

What is (your/NAME’S) job title? 

FOR EXAMPLE: Retail sales person, clerk, waiter, cook.

IF MORE THAN ONE JOB, PROBE FOR THE JOB PERSON CURRENTLY

SPENDS MOST TIME AT.

 |__|__| |__|__|

H6. What are (your/NAME’S) main duties as (a/an) (JOB TITLE FROM H5)?

PROBE: What are (your/NAME’S) responsibilities or activities?

What (do you/does NAME)spend the most time doing?

 |__|__| |__|__|

H7. How long (have you/has NAME) been working at this job?

IF MORE THAN ONE JOB, PROBE FOR JOB PERSON CURRENTLY

SPENDS MOST TIME AT.

RECORD TO THE NEAREST YEAR. IF LESS THAN ONE YEAR, RECORD

MONTHS.

|___|___| YEARS OR |___|___| MONTHS
H:\PROJECT\8305\012\Ques\wn-long.q7 47 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

H8. How likely is it that (you/NAME) will have this job three months from now? Would

you say it is very likely, somewhat likely, or not likely at all?

VERY LIKELY ......................... 01

SOMEWHAT LIKELY ................... 02

NOT LIKELY AT ALL ................... 03

DON’T KNOW ......................... -1

H9. Do you think (you/NAME) will be earning more, the same, or less three months

from now?

MORE ............................... 01

SAME ............................... 02

LESS ................................ 03

DON’T KNOW ......................... -1

H10. Including (your/NAME’s) present job, over the past 12 months, how many

different paid jobs (have you/has NAME) had? Please include all part-time and

full-time jobs held for at least two weeks.

CIRCLE ONE

ONE ................................ 01

TWO ................................ 02

THREE .............................. 03

FOUR ............................... 04

FIVE OR MORE ....................... 05

DON’T KNOW ......................... -1
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H11a. During the past 12 months, were there times when (you were/NAME was) not

working for pay?

YES ................................. 01

NO .................................. 00 ! SKIP TO J1

H11b. About how many months (were you/was NAME) not working for pay?

CIRCLE ONE

NONE ............................... 00

LESS THAN ONE MONTH ............... 01

BETWEEN 1 AND 3 MONTHS ............ 02

BETWEEN 4 AND 6 MONTHS ............ 03

BETWEEN 7 AND 9 MONTHS ............ 04

BETWEEN 10 AND 12 MONTHS .......... 05

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 49 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

I. NO SECTION I

J. SOCIAL SUPPORTS 

J1. How long have you lived in your neighborhood?

IF LESS THAN ONE YEAR, ENTER “00” FOR YEARS AND RECORD

NUMBER OF MONTHS.

|___|___| / |___|___|

 YEARS MONTHS

 OR

SINCE |___|___| 19 |___|___|

 MONTH YEAR

J2. NO QUESTION THIS VERSION.

J3. How close do you live to your nearest relative who does not live with you? Do

you live less than 30 minutes away, 30 minutes to 2 hours away, or more than 2

hours away?

CIRCLE ONE

LESS THAN 30 MINUTES AWAY .......... 01

30 MINUTES TO 2 HOURS AWAY ......... 02

MORE THAN 2 HOURS AWAY ............ 03

NO LIVING CHILDREN OR RELATIVES ..... -4
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K. INCOME AND EXPENSES

K1. Which of the following best describes where you live now . . .

A place you own, ........................ 01

A place you rent, ........................ 02 ! GO TO K5

A place where you live rent free, ............ 03 ! GO TO K6

Or someplace else? (SPECIFY) ............ 04 ! GO TO K6

 

 |___|___| |___|___|

K2. What is your monthly mortgage payment?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K3. (Do you/Does your household) make a separate home insurance payment?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

K4. (Do you/Does your household) pay a separate property tax bill?

YES .................................. 01

NO ................................... 00 SKIP TO K6

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 51 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

K5. What is your monthly rent payment? Please tell me only the amount that you and

members of your household pay out-of-pocket.

PROBE: Do not include any rent subsidies that your household receives from

any program to pay part of the rent costs.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K5a. (Do you/Does your household) pay separate heating or air-conditioning costs?

YES .................................. 01

NO ................................... 00

K6. INTERVIEWER: CHECK GRID A1 THROUGH A3. HOW MANY PEOPLE

ARE IN HOUSEHOLD?

ONE ................................. 01 ! SKIP TO K7b

MORE THAN ONE ...................... 02

K6a. Last month, did (you/your household) pay for the care of children or other

dependents so that someone in your household could go to work, school,

or a training program?

YES .................................. 01

NO ................................... 00 ! GO TO K7b

DON’T KNOW .......................... -1

K6b. How much did (you/your household) pay out-of-pocket last month?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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K7. NO QUESTION THIS VERSION.

K7a. NO QUESTION THIS VERSION.

K7b. Is anyone in your household disabled? Please count as disabled persons who

receive SSI benefits because of a disability, social security disability checks,

disability retirement pensions, railroad retirement disability payments, or veteran

disability benefits.

YES ................................. 01 ! SKIP TO K8

NO .................................. 00

DON’T KNOW ......................... -1

K7c. Is there anyone in your household who is age 60 or older?

YES ................................. 01

NO .................................. 00 

 SKIP TO K10

DON’T KNOW ......................... 00

K8. Last month, did (you/your household) pay health insurance premiums or

payments to belong to an HMO?

YES ................................. 01

NO .................................. 00 

 SKIP TO K9

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 53 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

K8a. How much did (you/your household) pay last month. Please tell me only the

amount that you and members of your household pay out-of-pocket.

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

K8b. NO QUESTION THIS VERSION.

K9. Now think about the people in your household who are disabled or age 60 or

older. Last month, how much were their out-of-pocket medical expenses? 

Include doctor and hospital bills, prescription drugs, lab tests or X-rays, and any

other medical expenses you paid out-of-pocket. Please exclude anything for

which you will be reimbursed.

$ |___|, |___|___|___|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\wn-long.q7 54 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

INTERVIEWER: CHECK GRID A1 THROUGH A3: IF RESPONDENT LIVES ALONE, DON’T ASK

K12, K13, OR K14. THAT IS, ALWAYS SKIP TO NEXT QUESTION IN K10 AFTER

COMPLETING K11 FOR EACH INCOME SOURCE.

K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

1. CO: Colorado Works; [STATE WELFARE NAME]/ DON’T

MA: Transitional Aid to Temporary Assistance for Needy NAME AMOUNT KNOW

Families with Dependent Families (TANF)?

Children; __________________ $ |___|,|___|___|___| -1

MN: MFIP Minnesota’s $ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

Family Investment __________________ $ |___|,|___|___|___| -1 

Program; DON’T NO ......... 00 6 GO TO K10.2

NC: Work First Benefits KNOW. . .-1 ! GO TO K12 __________________

PA/TX: Temporary $ |___|,|___|___|___| -1 

Assistance for Needy __________________

Families (TANF)?

YES ...... 01

NO ....... 00 6 ASK K12

$ |___|,|___|___|___| -1 

2. General Assistance, General Assistance, general relief, DON’T

general relief, or welfare? or welfare? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.3 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________

__________________ 

 

$ |___|,|___|___|___| -1

$ |___|,|___|___|___| -1 

3. Social Security checks Social Security checks from the DON’T

from the government? government? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.4 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

4. Other retirement benefits Other retirement benefits (that are DON’T

(that are not Social not Social Security) such as a NAME AMOUNT KNOW

Security) such as a government or private pension or

government or private annuity? __________________ $ |___|,|___|___|___| -1

pension or annuity? 

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.5 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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5. SSI or Supplemental SSI or Supplemental Security DON’T

Security Income from the Income from the federal, state, or NAME AMOUNT KNOW

federal, state, or local local government?

government? __________________ $ |___|,|___|___|___| -1

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.6 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

H:\PROJECT\8305\012\Ques\wn-long.q7 56 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

6. Veteran's benefits? Veteran's benefits? DON’T

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01

DON’T NO ......... 00 6 GO TO K10.7 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

NAME AMOUNT KNOW

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

7. Unemployment Insurance Unemployment Insurance or DON’T

or workman's workman's compensation NAME AMOUNT KNOW

compensation benefits? benefits?

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.8

KNOW. . .-1 ! GO TO K12 __________________

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________

$ |___|,|___|___|___| -1 

$ |___|,|___|___|___| -1 

8. Any child support Any child support payments or DON’T

payments or alimony? alimony? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12

DON’T 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K10.9 __________________ $ |___|,|___|___|___| -1 

YES ......... 01 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

9. Payments from roomers or Payments from roomers or DON’T

boarders? boarders? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.10 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 

10. Financial support from Financial support from friends or DON’T

friends or family? family? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.11 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

H:\PROJECT\8305\012\Ques\wn-long.q7 57 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

11. Any other income such as Any other income such as income DON’T

income from business or from business or prizes? NAME AMOUNT KNOW

prizes?

YES ..... 01 ! (SPECIFY)

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 __________________ $ |___|,|___|___|___| -1 

DON’T __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K15

YES ......... 01 ! SPECIFY

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
H:\PROJECT\8305\012\Ques\wn-long.q7 58 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

K15. Do you (or does anybody in your household) own a car, truck, van, or

motorcycle? Please include any cars, trucks, vans, or motorcycles 

that you’re making payments on.

YES ................................. 01

NO .................................. 00 ! SKIP TO K18

K16. What (is/are) the year(s), make(s), and model(s) of the car(s), truck(s), van(s), or

motorcycle(s)?

PROBE: Please include any

vehicle owned by a

household members.

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

DON’T KNOW ......................... -1 ! ASK K17

SKIP TO K18

K17. INTERVIEWER: IF YEAR, MAKE OR MODEL ARE UNKNOWN, ASK: 

What is the approximate value of each vehicle owned by household members?

Vehicle 1: $ ________________________

Vehicle 2: $ ________________________

Vehicle 3: $ ________________________
H:\PROJECT\8305\012\Ques\wn-long.q7 59 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

K18. (Including yourself, is anyone in your household/Are you) legally required to pay

child support?

YES ................................. 01

NO .................................. 00 ! SKIP TO L2

K19. In total, how much child support (was paid by all members of your household/did

you pay) last month?

$ |___|___|,|___|___|___| ! SKIP TO L2

DON’T KNOW ......................... -1

REFUSED ............................ -3

K20. Would you tell me which of the following ranges best describes the total amount

of child support paid last month?

More than $250 ........................ 01 ! SKIP TO K22

Exactly $250 .......................... 02 ! SKIP TO L2

Less than $250 ........................ 03

DON’T KNOW/REFUSED ................ -3 ! SKIP TO L2

K21. Was it . . .

$50 or less, ........................... 01

Between $51 and $100, ................. 02

Between $101 and $150, ................ 03 SKIP TO L2

Between $151 and $200, ................ 04

Or, between $201 and $250? ............. 05

DON’T KNOW/REFUSED ................ -3
H:\PROJECT\8305\012\Ques\wn-long.q7 60 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

K22. Was it . . .

Between $250 and $300, ................ 01

Between $301 and $350, ................ 02

Between $351 and $400, ................ 03

Between $401 and $450, ................ 04

Or, over $450? ........................ 05

DON’T KNOW/REFUSED ................ -3
H:\PROJECT\8305\012\Ques\wn-long.q7 61 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

L. DEMOGRAPHIC INFORMATION

L1. NO QUESTION THIS VERSION.

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................... 01

FEMALE ............................ 00

L3. Are you now . . .

Married, ............................. 01

Living with someone as married, .......... 02

Widowed, ............................ 03

Divorced, ............................ 04

Separated, ........................... 05

Or have you never been married? ......... 06
H:\PROJECT\8305\012\Ques\wn-long.q7 62 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ........................ 01

SECOND GRADE ...................... 02

THIRD GRADE ........................ 03

FOURTH GRADE ...................... 04

FIFTH GRADE ........................ 05

SIXTH GRADE ........................ 06

SEVENTH GRADE ..................... 07

EIGHTH GRADE ....................... 08

NINTH GRADE ........................ 09

TENTH GRADE ....................... 10

ELEVENTH GRADE .................... 11

TWELFTH GRADE ..................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) . . 13

GED ................................ 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ......................... 15

SOME COLLEGE ...................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE ............................. 17

OTHER (SPECIFY) ..................... 18

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

REFUSED ............................ -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\wn-long.q7 63 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7. Is everyone in your household a U.S. citizen?

YES .................................. 01 ! SKIP TO L8

NO ................................... 00

L7a. Is anyone in your household a U.S. citizen?

YES .................................. 01

NO ................................... 00

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
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M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT .......................... 01

GOOD ............................... 02

FAIR ................................ 03

POOR ............................... 04

M2. Did the respondent seem to have any trouble understanding English?

YES ................................. 01

NO .................................. 00

M3. Were there any questions that the respondent complained about?

YES ................................. 01

NO .................................. 00 ! SKIP TO M4

M3a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\wn-long.q7 65 (REV - 1/21/98-WP70) 12/16/99 11:19 AM

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8--TAN QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 10:54 AM

OMB No.: 0584-0486

Expiration Date: 11/98

WORKING NONPARTICIPANT

SHORT INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

_______ ___/___ _____A/P _____ ___/___ _____A/P

_______ ___/___ _____A/P _____ ___/___ _____A/P

_______ ___/___ _____A/P _____ ___/___ _____A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 2 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Working Nonparticipant--Short

A. HOUSEHOLD COMPOSITION

A1s. How many people in your household are 60 years of age or older? By household

I mean yourself and the people who currently live with you and share food with

you.

PROBE: Include any persons who live with you more than half time.

|___|___|

A2s. Including yourself, how many people in your household are under 18 years of

age?

|___|___|

A3s. Including yourself, how many people in your household currently work at a job for

pay?

|___|___|

NONE ............................... 00 ! SKIP TO C1

A4s. Do you work at a job for pay?

YES ................................. 01

NO .................................. 00
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 3 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

B. NO SECTION B

C. FSP PARTICIPATION HISTORY

C1. Have you received food stamp benefits in the past 3 years?

YES ................................. 01

NO .................................. 00 ! SKIP TO D1

C2.-

C2a. NO QUESTIONS THIS VERSION.

C3. When was the last time you received food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

C3a. INTERVIEWER: IS DATE MORE THAN THREE YEARS AGO?

YES ................................. 01 ! SKIP TO D1

NO .................................. 00

DON’T KNOW ......................... -1

C4. How did you get your food stamp benefits in (DATE FROM C3)? Did you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ........................... 01

EBT CARD ........................... 02
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C4a. What was the amount of food stamp benefits you received in (DATE FROM C3)?

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

C5. Did you stop receiving food stamp benefits in (DATE FROM C3) because you

were notified that you were not eligible?

YES ................................. 01 ! SKIP TO C13a

NO .................................. 00
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 5 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

C6. Why did you stop participating in the food stamp program in (DATE FROM C3)? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

NOT WORTH THE EFFORT FOR

THE AMOUNT OF BENEFITS ............ 01

NO LONGER NEEDED FOOD STAMP

BENEFITS ............................ 02

EMBARRASSED USING FOOD STAMP

BENEFITS ............................ 03

THOUGHT NO LONGER ELIGIBLE ........ 04

THOUGHT SITUATION WOULD

IMPROVE ............................ 05

HARD TO GET TO FOOD STAMP OFFICE . . 06

PROCESS OF RECEIVING FOOD

STAMP BENEFITS IS TOO LONG

OR COMPLICATED .................... 07

HAD TO ANSWER TOO MANY

PERSONAL QUESTIONS ................ 08

FAMILY MEMBERS DISAPPROVED

OF MY/OUR RECEIVING FOOD

STAMP BENEFITS ..................... 09

DO NOT LIKE TO RELY ON

GOVERNMENT ASSISTANCE ............ 10

OTHER PEOPLE NEEDED THEM MORE ... 11

NOT TREATED WELL BY STAFF ......... 12

OFFICE IS VERY UNPLEASANT .......... 13

OFFICE IN AN UNSAFE

NEIGHBORHOOD ..................... 14

OTHER (SPECIFY) ..................... 15

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 6 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

C7.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO C13c

REFUSED ............................ -3

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 7 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

SKIP TO C13c

C13a. Why were you found ineligible? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

C13b. NO QUESTION THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 8 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

C13c. When you received food stamps in the past three years, did you ever do things

so that people would not find out you received food stamp benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ................................. 01

NO .................................. 00

C14. Now I’m going to ask you some questions about your experiences with food

stamp benefits over the past three years.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in

stores, were you sometimes treated

disrespectfully by either employees or

customers? ........................ 01 00

b. Were you embarrassed to use food stamp

benefits? .......................... 01 00

c. Did you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Did you feel that you really needed food

stamp benefits to make it through the

month? ............................ 01 00

e. Did you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Did you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Did food stamp office staff ever treat you

disrespectfully? ..................... 01 00
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 9 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

C15. Did you experience other difficulties with food stamp benefits that you have not

already mentioned? Please do not include any difficulties you had applying, we

will ask about this later.

YES ................................. 01

NO .................................. 00 ! SKIP TO D1

C16. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 10 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D. HISTORY OF APPLICATIONS

D1. Have you applied for food stamp benefits in the past 3 years? By applied I mean

have you at least completed a new application form?

YES ................................. 01

NO .................................. 00 

SKIP TO D8

DON’T KNOW ......................... -1

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH/YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 11 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ................................ 01 ! SKIP TO D4c

NO ................................. 00

DON’T KNOW ........................ -1

D4b. Did you or someone else mail or take the application for to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ....................... 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02
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D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ................ 01

AT SSI OFFICE ......................... 02

AT A SENIOR CENTER .................. 03 SKIP TO D4f

AT A HOSPITAL ........................ 04

AT A HOUSING COMPLEX ............... 05

SOMEWHERE ELSE (PLEASE SPECIFY) ... 06

 

 |__|__| |__|__|

AT HOME ............................. 07

D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ........................ 01

VISIT BY CASEWORKER ................ 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

DOESN’T WORK ....................... -4

D4g. The last time you applied, did you have a lot of help with the application?

YES ................................. 01

NO .................................. 00 

SKIP TO D5

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 13 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D4h. What type of help did you receive? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D4i. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 14 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

|__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 15 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ..................................... 01

NO ...................................... 00 ! SKIP TO D8
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 16 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D7b. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ..................................... 01

NO ...................................... 00

DON’T KNOW ............................. -1 SKIP TO D10

REFUSED ................................ -3
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 17 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE .................... 01

BENEFIT TOO LOW ........................ 02

APPLICATION TOO TIME-CONSUMING ........ 03

APPLICATION FORM TOO COMPLICATED ..... 04

APPLICATION TOO PERSONAL .............. 05

TOO MUCH PAPERWORK .................. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ........................... 07

NOT TREATED WELL BY STAFF ............. 08

STIGMA/EMBARRASSMENT/PRIDE ........... 09

HEALTH/MOBILITY PROBLEMS .............. 10

LANGUAGE/LITERACY PROBLEMS ........... 11

MY SITUATION CHANGED .................. 12

TRANSPORTATION PROBLEM ............... 13

HARD TO GET TIME OFF WORK ............. 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ..................... 15

OTHER (SPECIFY) ......................... 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 18 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ..................................... 01

NO ...................................... 00 SKIP TO D12

DON’T KNOW ............................. -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH ........................ 01

TOO MANY ASSETS ....................... 02

MISSING PAPERWORK ..................... 03

CITIZENSHIP STATUS ...................... 04

DID NOT SATISFY WORK REQUIREMENTS .... 05

ON STRIKE FROM JOB ..................... 06

OTHER (SPECIFY) ......................... 07

 

 |__|__| |__|__|

DON’T KNOW ............................. -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 19 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them 

but did not use any of them.

YES ..................................... 01

NO ...................................... 00 

SKIP TO E1

DON’T KNOW ............................. -1

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP

BENEFITS ................................ 01

NOT TREATED WELL IN FOOD STORES ...... 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ................... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS ...... 04

NOT TREATED WELL BY OFFICE/

PROGRAM ............................... 05

TOO HARD TO PICK UP COUPONS/STAMPS ... 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN .............................. 07

BENEFIT AMOUNT WAS TOO SMALL ......... 08

DID NOT NEED FOOD STAMPS .............. 09

OTHER (SPECIFY) ......................... 10

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 20 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

GO TO E1

D14. Have you contacted the food stamp office to ask about food stamp benefits in

the past 3 years?

YES ..................................... 01

NO ...................................... 00 ! SKIP TO E1

D15.-

D16b. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 21 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

D16c. Why didn’t you complete an application form at that time? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE .................... 01

BENEFIT TOO LOW ........................ 02

APPLICATION TOO TIME-CONSUMING ........ 03

APPLICATION FORM TOO COMPLICATED ..... 04

APPLICATION TOO PERSONAL .............. 05

TOO MUCH PAPERWORK .................. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ........................... 07

NOT TREATED WELL BY STAFF ............. 08

STIGMA/EMBARRASSMENT/PRIDE ........... 09

HEALTH/MOBILITY PROBLEMS .............. 10

LANGUAGE/LITERACY PROBLEMS ........... 11

MY SITUATION CHANGED .................. 12

TRANSPORTATION PROBLEM ............... 13

HARD TO GET TIME OFF WORK ............. 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ..................... 15

OTHER (SPECIFY) ......................... 16

 

 |__|__| |__|__|

D17.-

D21. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 22 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E. NONPARTICIPATION

Now I would like to talk to you about the reasons you currently do not use food stamps.

E1. E2. E4.

Is this an important reason

you don’t use food stamp

benefits?

YES NO KNOW YES NO KNOW REASON

DON’T DON’T IMPORTANT

MOST

a. Do you know where to go or who to

contact to apply for food stamp SKIP 

benefits? ...................... 01 !TO E1b 00 -1 01 00 -1 01

b. Do you think you are currently eligible SKIP 

for food stamp benefits? .......... 01 !TO E1c 00 -1 01 00 -1 02

c. Do you think it would be hard to get SKIP SKIP 

to the food stamp office? .......... 01 00 ! TO E1d -1 !TO E1d 01 00 -1 03

d. Do you think the application process SKIP SKIP 

is too long and complicated? ....... 01 00 ! TO E1e -1 !TO E1e 01 00 -1 04

e. Do you think you would have to

answer questions that are too

personal when applying for food SKIP SKIP 

stamp benefits? ................. 01 00 ! TO E1f -1 ! TO E1f 01 00 -1 05

f. Do you think you would feel

embarrassed applying for SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1g -1 !TO E1g 01 00 -1 06

g. Do you think you would be eligible for

only a small amount of food stamp SKIP SKIP 

benefits? ...................... 01 00 ! TO E1h -1 !TO E1h 01 00 -1 07

h. Can you get by on your own without SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1i -1 ! TO E1i 01 00 -1 08

i. Do you feel that others need food SKIP SKIP 

stamp benefits more than you do? . . 01 00 ! TO E1j -1 ! TO E1j 01 00 -1 09

j. Would you feel embarrassed using SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1k -1 !TO E1k 01 00 -1 10

k. Would you dislike relying on SKIP SKIP 

government assistance? .......... 01 00 ! TO E1l -1 ! TO E1l 01 00 -1 11

l. Would other family members or

friends discourage you from using SKIP SKIP 

food stamp benefits? ............. 01 00 !TO E1m -1 !TO E1m 01 00 -1 12

m. Do you think that staff at the food

stamp office would treat you SKIP SKIP 

disrespectfully? ................. 01 00 ! TO E1n -1 !TO E1n 01 00 -1 13

n. Do you think that the food stamp

office would be very unpleasant or SKIP SKIP 

you would not be safe? ........... 01 00 ! TO E1o -1 !TO E1o 01 00 -1 14

o. Do you think your need for food SKIP SKIP 

stamp benefits is only temporary? ... 01 00 ! TO E1p -1 !TO E1p 01 00 -1 15
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 23 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

p. Are there other important reasons

why you do not use food stamp

benefits that we have not just SKIP SKIP

mentioned? ....................

RECORD VERBATIM BELOW:

01 00 ! TO E3 -1 ! TO E3 01 00 -1 16
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 24 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E3. INTERVIEWER: HOW MANY “YESES” ARE CIRCLED IN QUESTION E2?

NONE ................................ 00 

SKIP TO E5

ONE ................................. 01

MORE THAN ONE ...................... 02

E4. Of all the reasons you gave (READ IMPORTANT REASONS FROM E2 IF

NECESSARY), what is the most important reason you do not currently use food

stamp benefits? RECORD IN COLUMN MARKED E4.

E5. INTERVIEWER: WAS THE RESPONSE TO E1b “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E7

E6. You said you think you are currently eligible for food stamp benefits. How much

in food stamp benefits do you think you would qualify for each month? Your best

estimate is fine.

CIRCLE ONE RESPONSE

$10 OR LESS ......................... 01

BETWEEN $11 AND $25 ................ 02

BETWEEN $26 AND $50 ................ 03

BETWEEN $51 AND $100 ............... 04

BETWEEN $101 AND $150 .............. 05

BETWEEN $151 AND $200 .............. 06

BETWEEN $201 AND $300 .............. 07

MORE THAN $300 ..................... 08

DON’T KNOW ......................... -1

GO TO E9
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 25 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E7. You said you think you are not currently eligible for food stamp benefits. Why do

you think that you are not eligible to receive food stamp benefits? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DO NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

E8. Do you think you are currently ineligible because you were told by someone at

the food stamp office that you are ineligible?

YES ................................. 01

NO .................................. 00 ! SKIP TO E8b

E8a. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN THE LAST MONTH .............. 01

WITHIN THE LAST 3 MONTHS ........... 02

WITHIN THE LAST YEAR ............... 03

MORE THAN ONE YEAR AGO ........... 04

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 26 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E8b. Were you told by someone at another program that you are ineligible for food

stamp benefits?

YES ................................. 01 ! SKIP TO E9

NO .................................. 00

DON’T KNOW ......................... -1

E8c. Do you think you are ineligible because you know someone like you who is

ineligible?

YES ................................. 01

NO .................................. 00

E9. INTERVIEWER: WAS THE RESPONSE TO E1c “YES”?

YES ................................. 01

NO .................................. 00 ! SKIP TO E11

E10. You said you think it would be hard to get to the food stamp office. Is this . . .

YES NO

a. Because it is difficult or expensive to get

transportation? ................................... 01 00

b. Because of difficulties you have getting around? ......... 01 00

c. Because of difficulties you would have taking time

off work? ........................................ 01 00

d. Because you would lose pay going to the

food stamp office? ................................ 01 00

e. Because you would have to pay for someone

to take care of someone in your home? ................ 01 00

f. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ...............................

|__|__| |__|__|

01 00
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 27 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E11. INTERVIEWER: WAS THE RESPONSE TO E1d “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12. You think the application process would be too long and complicated. Is

this . . .

YES NO

a. Because you think you would have to wait a long time

to be served? .................................... 01 00

PROBE: A long time from your point of view.

b. Because you think the application form is too long and

complicated? ..................................... 01 00

c. Because you think it would be difficult to get all the necessary

paperwork? ...................................... 01 00

d. Because of some other reason I haven’t mentioned? ......

(PLEASE SPECIFY) ...............................

|__|__| |__|__|

01 00

E12a. INTERVIEWER: WAS THE RESPONSE TO PART “a” OF E12 “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12b. You said you would have to wait a long time to be served. How long do you think

you would have to wait? Would it be . . .

15 minutes or less? ...................... 01

16 to 30 minutes? ....................... 02

31 minutes to one hour? .................. 03

Or, more than one hour? .................. 04

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 28 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E13. INTERVIEWER: WAS THE RESPONSE TO E1e “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E15

E14. You said you would have to answer questions that were too personal. What type

of questions do you feel are too personal?

CIRCLE ALL THAT APPLY

WHO LIVES IN HOUSEHOLD ............. 01

CITIZENSHIP .......................... 02

DISABILITIES .......................... 03

RESOURCES/ASSETS .................. 04

INCOME .............................. 05

MEDICAL EXPENSES ................... 06

DEPENDENT-CARE EXPENSES ........... 07

SHELTER EXPENSES ................... 08

CHILD-SUPPORT PAYMENTS ............ 09

OTHER (SPECIFY) ...................... 10

 

 |__|__| |__|__|

E15. INTERVIEWER: WAS THE RESPONSE TO E1g “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E17

E16. You said you think you are eligible for only a small amount of food stamp

benefits.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 29 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E16a. Were you told by someone at a food stamp office that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01

NO ................................ 00 

 SKIP TO E16c

DON’T KNOW ....................... -1

E16b. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN LAST MONTH ................ 01

WITHIN LAST 3 MONTHS ............. 02

WITHIN THE LAST YEAR ............. 03

MORE THAN ONE YEAR AGO ......... 04

DON’T KNOW ....................... -1

GO TO E17

E16c. Were you told by someone at another program that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01 ! SKIP TO E17

NO ................................ 00

DON’T KNOW ....................... -1

E16d. Do you think that you would receive only a small amount of benefits because you

know someone like you who receives only a small amount of benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 30 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

E17. INTERVIEWER: WAS THE RESPONSE TO E1n “YES”?

YES ............................... 01

NO ................................ 00 ! SKIP TO E19

E18. You thought the food stamp office would be very unpleasant or you would not be

safe? Is this . . .

YES NO

a. Because the inside of the building would be

unpleasant? ................................ 01 00

b. Because you wouldn’t like waiting with the other

applicants? ................................. 01 00

c. Because the office would be in an unsafe

neighborhood? .............................. 01 00

d. Because of something else? (SPECIFY) ......... 01 00

|__|__| |__|__|

E19. Do you agree with the statement made by some people that “its OK to receive

food stamp benefits if you pay taxes”?

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 31 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

F. NO SECTION F

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G2.-

G4. NO QUESTIONS THIS VERSION.

G4s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G9

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 32 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

G6.-

G8. NO QUESTIONS THIS VERSION.

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G13

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G10.-

G12. NO QUESTIONS THIS VERSION.

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 

 SKIP TO G14s

DON’T KNOW ......................... -1

G14. NO QUESTION THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 33 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

G14s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO L1

G15. NO QUESTION THIS VERSION.

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G17.-

G19. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 34 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

H. NO SECTION H

I. NO SECTION I

J. NO SECTION J

K. NO SECTION K

L. DEMOGRAPHIC INFORMATION

L1. Now, I have just a few final questions.

Can you tell me your age?

|___|___| / |___|___| / 19 |___|___|

MONTH DAY YEAR

OR |___|___| YEARS OLD

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................... 01

FEMALE ............................. 00

L3. Are you now . . .

Married, .............................. 01

Living with someone as married, ........... 02

Widowed, ............................ 03

Divorced, ............................. 04

Separated, ............................ 05

Or have you never been married? .......... 06
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 35 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ........................ 01

SECOND GRADE ...................... 02

THIRD GRADE ........................ 03

FOURTH GRADE ...................... 04

FIFTH GRADE ........................ 05

SIXTH GRADE ........................ 06

SEVENTH GRADE ..................... 07

EIGHTH GRADE ....................... 08

NINTH GRADE ........................ 09

TENTH GRADE ....................... 10

ELEVENTH GRADE .................... 11

TWELFTH GRADE ..................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) . . 13

GED ................................ 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ......................... 15

SOME COLLEGE ...................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE ............................. 17

OTHER (SPECIFY) ..................... 18

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

REFUSED ............................ -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 36 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7-

L7a. NO QUESTIONS THIS VERSION.

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 37 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT ........................... 01

GOOD ................................ 02

FAIR ................................. 03

POOR ................................ 04

M2. Did the respondent seem to have any trouble understanding English?

YES .................................. 01

NO ................................... 00

M3. Were there any questions that the respondent complained about?

YES .................................. 01

NO ................................... 00 ! SKIP TO M4
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 38 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01 

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\WN-SHORT.Q8 39 (REV - 1/21/98--WP70) 12/16/99 10:54 AM

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7--BLUE QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 11:33 AM

OMB No.: 0584-0486

Expiration Date: 11/98

WORKING PARTICIPANT

SHORT INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 2 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Working Participant--Short

A. HOUSEHOLD COMPOSITION

A1s. How many people in your household are 60 years of age or older? By household

I mean yourself and the people who currently live with you and share food and

other resources.

PROBE: Include any persons who live with you more than half time.

|___|___|

A2s. Including yourself, how many people in your household are under 18 years of

age?

|___|___|

A3s. Including yourself, how many people in your household currently work at a job for

pay?

|___|___|

NONE ............................. 00 ! SKIP TO C4

A4s. Do you work at a job for pay?

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 3 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

B. NO SECTION B

C. FSP PARTICIPATION HISTORY

C1.-

C3. NO QUESTIONS THIS VERSION.

C4. How do you currently get your food stamp benefits each month? Do you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ......................... 01

EBT CARD ......................... 02

C4a.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1 SKIP TO C13c

REFUSED .......................... -3
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 4 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................. 01

TOO MANY ASSETS ................. 02

MISSING PAPERWORK ............... 03

CITIZENSHIP STATUS ................ 04

DID NOT SATISFY WORK

REQUIREMENTS .................... 05

ON STRIKE FROM JOB ............... 06

OTHER (SPECIFY) ................... 07

 

 |__|__| |__|__|

DON’T KNOW ....................... -1

C13a.-

C13b. NO QUESTIONS THIS VERSION.

C13c. Do you ever do things so that people will not find out you receive food stamp

benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 5 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

C14. Now I’m going to read some statements about experiences with food stamp

benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in stores are

you sometimes treated disrespectfully by

either employees or other customers? .... 01 00

b. Are you embarrassed to use food stamp

benefits? .......................... 01 00

c. Do you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Do you feel that you really need food stamp

benefits to make it through the month? ... 01 00

e. Do you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Do you have any difficulties arranging

meetings with your caseworker at convenient

times ............................. 01 00

g. Do food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Have you experienced other difficulties with food stamp benefits that you have

not already mentioned? Please do not include any difficulties you had applying,

we will ask about this later.

YES ............................... 01

NO ................................ 00 ! SKIP TO D2

C16. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 6 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D. HISTORY OF APPLICATIONS

D1. NO QUESTION THIS VERSION.

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI) AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 7 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ............................... 01 ! SKIP TO D4c

NO ................................ 00

DON’T KNOW ....................... -1

D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ........................ 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 8 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ................ 01

AT SSI OFFICE ......................... 02

AT A SENIOR CENTER .................. 03 SKIP TO D4f

AT A HOSPITAL ........................ 04

AT A HOUSING COMPLEX ............... 05

SOMEWHERE ELSE (PLEASE SPECIFY) ... 06

 

 |__|__| |__|__|

AT HOME ............................. 07

D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ........................ 01

VISIT BY CASEWORKER ................ 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

DOESN’T WORK ....................... -4

D4g.-

D4i. NO QUESTIONS THIS VERSION.

D5.-

D6. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 9 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? .............................. 01 00 --

b. Did you have to go to the food stamp office even though your

health or disability made it difficult? .................... 01 00 --

c. Was it difficult for you to take time off from work to apply for

food stamp benefits? ............................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ........................................ 01 00 -4

e. Did you have to arrange for care of someone in your home so

that you could go to the food stamp office? .............. 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ..................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ......... 01 00 --

h. Do you think the application form was too long and

complicated? ..................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ........................................ 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? ...................................... 01 00 --

k. Did you feel embarrassed having to apply for

food stamps? ..................................... 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ............................... 01

NO ................................ 00 ! SKIP TO D8
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 10 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D7b. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1 SKIP TO D10

REFUSED .......................... -3
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 11 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE .............. 01

BENEFIT TOO LOW .................. 02

APPLICATION TOO TIME-CONSUMING . . 03

APPLICATION FORM TOO

COMPLICATED ..................... 04

APPLICATION TOO PERSONAL ........ 05

TOO MUCH PAPERWORK ............ 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ..................... 07

NOT TREATED WELL BY STAFF ....... 08

STIGMA/EMBARRASSMENT/PRIDE ..... 09

HEALTH/MOBILITY PROBLEMS ........ 10

LANGUAGE/LITERACY PROBLEMS ..... 11

MY SITUATION CHANGED ............ 12

TRANSPORTATION PROBLEM ......... 13

HARD TO GET TIME OFF WORK ....... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ............... 15

OTHER (SPECIFY) ................... 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 12 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ............................... 01

NO ................................ 00 

SKIP TO D12

DON’T KNOW ....................... -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................. 01

TOO MANY ASSETS ................. 02

MISSING PAPERWORK ............... 03

CITIZENSHIP STATUS ................ 04

DID NOT SATISFY WORK

REQUIREMENTS .................... 05

ON STRIKE FROM JOB ............... 06

OTHER (SPECIFY) ................... 07

 

 |__|__| |__|__|

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 13 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them 

but did not use any of them.

YES ............................... 01

NO ................................ 00 

SKIP TO D17

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 14 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM AND

CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP 

BENEFITS .......................... 01

NOT TREATED WELL IN FOOD

STORES. .......................... 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ............. 03

DID NOT LIKE TO SHOP AT

STORES THAT ACCEPT FOOD 

STAMP BENEFITS ................... 04

NOT TREATED WELL BY OFFICE/

PROGRAM ......................... 05

TOO HARD TO PICK UP COUPONS/

STAMPS ........................... 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN ........................ 07

BENEFIT AMOUNT WAS TOO SMALL ... 08

DID NOT NEED FOOD STAMPS ........ 09

OTHER (SPECIFY) ................... 10

 

 |__|__| |__|__|

D14.-

D16. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 15 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

(PLEASE SPECIFY):

|__|__| |__|__|

D17. Now I would like to talk to you about some things that may have helped you decide to

use food stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. Did you receive a lot of help with the

application? ........................ 01 00

b. Did other family members or friends 

encourage you to get food stamp 

benefits? .......................... 01 00

c. Do you feel it’s OK to receive food stamp

benefits because you pay taxes? ........ 01 00

d. Do you feel you couldn’t get by on your own

without food stamp benefits? ........... 01 00

e. Are you uncomfortable getting food 

from family, friends, charities, or other 

programs? ......................... 01 00

D18. Are there other circumstances that I haven’t mentioned that helped you decide to use

food stamp benefits?

YES ............................... 01

NO ................................ 00

D19. INTERVIEWER: CHECK QUESTION D17a. DID THEY RECEIVE A LOT OF HELP

WITH THE APPLICATION?

YES ............................... 01

NO ................................ 00 ! SKIP TO G1
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 16 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

D20. You said you received a lot of help with the application, what type of help did you

receive? RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D21. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 17 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

E. NO SECTION E

F. NO SECTION F

G. FOOD SECURITY

G1. 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 12 months, that is,

since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G2.-

G4. NO QUESTIONS THIS VERSION.

G4s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN UNDER

18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G9
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 18 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the children)

because (I was/we were) running out of money to buy food.” Was that often, sometimes,

or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G6.-

G8. NO QUESTIONS THIS VERSION.

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G13

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G10.-

G12. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 19 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 

 SKIP TO G14s

DON’T KNOW ......................... -1

G14. NO QUESTION THIS VERSION.

G14s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO L1

G15. NO QUESTION THIS VERSION.

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G17.-

G19. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 20 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

H. NO SECTION H

I. NO SECTION I

J. NO SECTION J

K. NO SECTION K

L. DEMOGRAPHIC INFORMATION

L1. Now, I have just a few final questions.

Can you tell me your age?

|___|___| / |___|___| / 19 |___|___|

MONTH DAY YEAR

OR |___|___| YEARS OLD

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................. 01

FEMALE ........................... 00

L3. Are you now . . .

Married, ............................ 01

Living with someone as married, ......... 02

Widowed, .......................... 03

Divorced, ........................... 04

Separated, .......................... 05

Or have you never been married? ........ 06
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 21 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ...................... 01

SECOND GRADE .................... 02

THIRD GRADE ...................... 03

FOURTH GRADE .................... 04

FIFTH GRADE ...................... 05

SIXTH GRADE ...................... 06

SEVENTH GRADE ................... 07

EIGHTH GRADE ..................... 08

NINTH GRADE ...................... 09

TENTH GRADE ..................... 10

ELEVENTH GRADE .................. 11

TWELFTH GRADE ................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) 13

GED .............................. 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ....................... 15

SOME COLLEGE .................... 16

TWO- OR FOUR-YEAR COLLEGE DEGREE17

OTHER (SPECIFY) ................... 18

 

 |__|__| |__|__|

DON’T KNOW ....................... -1

REFUSED .......................... -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

REFUSED .......................... -3
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 22 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7.-

L7a. NO QUESTIONS THIS VERSION.

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 23 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT ........................ 01

GOOD ............................. 02

FAIR .............................. 03

POOR ............................. 04

M2. Did the respondent seem to have any trouble understanding English?

YES ............................... 01

NO ................................ 00

M3. Were there any questions that the respondent complained about?

YES ............................... 01

NO ................................ 00 ! SKIP TO M4
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 24 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ............................... 01

NO ................................ 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\WP-SHORT.Q7 25 (REV - 1/21/98--WP70) 12/16/99 11:33 AM

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\WP-LONG.Q6--PINK QC: CODER: _______________ DATE: _______________

(REV - 1/16/98--WP70) 12/16/99 1:16 PM

OMB No.: 0584-0486

Expiration Date: 11/98

WORKING PARTICIPANT

LONG INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

_______ ___/___ _____A/P _____ ___/___ ______A/P

_______ ___/___ _____A/P _____ ___/___ ______A/P

_______ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 2 (REV--1/16/98--WP70) 12/16/99 1:16 PM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Working Participant--Long

A. HOUSEHOLD COMPOSITION

A1. Please tell me the first name or initials of each person who currently lives in your

household starting with you. By household I mean people who live with you and

share food with you.

PROBE: Include any persons who live with you more than half time.

A2. How is (NAME) related to you? ENTER CODE BELOW.

A3. How old (are you/is NAME)? PROBE: Your best estimate is fine.

Person

Number First Name or Initials Relationship Age

A1. A2. A3.

1. __________________________________ SELF

|___|___|

DON’T KNOW .......... -1

2. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

3. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

4. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

5. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

6. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

7. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

8. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

9. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1

10. __________________________________ |___|___|

|___|___|

DON’T KNOW .......... -1
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 3 (REV--1/16/98--WP70) 12/16/99 1:16 PM

RELATIONSHIP CODES

01 MALE SPOUSE/PARTNER 06 GRANDMOTHER 11 OTHER MALE RELATIVE

02 FEMALE SPOUSE/PARTNER 07 SON/STEPSON OR NONRELATIVE

03 FATHER/STEPFATHER 08 DAUGHTER/STEPDAUGHTER 12 OTHER FEMALE RELATIVE

04 MOTHER/STEPMOTHER 09 BROTHER/STEPBROTHER OR NONRELATIVE

05 GRANDFATHER 10 SISTER/STEPSISTER
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 4 (REV--1/16/98--WP70) 12/16/99 1:16 PM

A4. I’ve recorded the following names (READ NAMES FROM A1). Is there anyone

else such as babies or small children? Anyone who usually lives with you but is

now away from home, or, anyone else staying here?

YES ............................ 01 ! GO BACK AND

CORRECT A1-A3

NO ............................. 00
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 5 (REV--1/16/98--WP70) 12/16/99 1:16 PM

B. KNOWLEDGE OF THE FSP

B0. NO QUESTION THIS VERSION.

B1. As far as you know, did your family ever receive food stamp benefits when you

were a child?

YES ............................ 01

NO ............................. 00

B2. As far as you know, do any of your relatives, neighbors, or co-workers currently

receive food stamp benefits?

YES ............................ 01

NO ............................. 00

DON’T KNOW .................... -1

B3.-

B8. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 6 (REV--1/16/98--WP70) 12/16/99 1:16 PM

C. FSP PARTICIPATION HISTORY

C1.-

C3. NO QUESTIONS THIS VERSION.

C4. How do you currently get your food stamp benefits each month? Do you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ....................... 01

EBT CARD ....................... 02

C4a.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ............................ 01

NO ............................. 00

DON’T KNOW .................... -1 SKIP TO C13c

REFUSED ....................... -3
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 7 (REV--1/16/98--WP70) 12/16/99 1:16 PM

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

CIRCLE ALL THAT APPLY

INCOME TOO HIGH ............... 01

TOO MANY ASSETS .............. 02

MISSING PAPERWORK ............ 03

CITIZENSHIP STATUS ............. 04

DID NOT SATISFY WORK

REQUIREMENTS ................. 05

ON STRIKE FROM JOB ............ 06

OTHER (SPECIFY) ................ 07

 

 |__|__| |__|__|

DON’T KNOW .................... -1

C13a.-

C13b. NO QUESTIONS THIS VERSION.

C13c. Do you ever do things so that people will not find out you receive food stamp

benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ............................ 01

NO ............................. 00
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 8 (REV--1/16/98--WP70) 12/16/99 1:16 PM

C14. Now I’m going to read some statements about experiences with food stamp

benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in stores,

are you sometimes treated disrespectfully by

either employees or other customers? .... 01 00

b. Are you embarrassed to use food stamp

benefits? .......................... 01 00

c. Do you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Do you feel that you really need food stamp

benefits to make it through the month? ... 01 00

e. Do you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Do you have any difficulties arranging

meetings with your caseworker at convenient

times? ............................ 01 00

g. Do food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Have you experienced other difficulties with food stamp benefits that you

have not already mentioned? Please do not include any difficulties you had

applying, we will ask about this later.

YES ..................... 01

NO ...................... 00 ! SKIP TO D2

C16. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 9 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D. HISTORY OF APPLICATIONS

D1. NO QUESTION THIS VERSION.

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES .................................. 01 ! SKIP TO D4c

NO ................................... 00

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 10 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

PROBE: That is, did you or someone else mail or take the application to . . .

CIRCLE ONE

AN SSI OFFICE, ........................ 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE .............. 01

AT SSI OFFICE ....................... 02

AT A SENIOR CENTER ................ 03 SKIP TO D4f

AT A HOSPITAL ...................... 04

AT A HOUSING COMPLEX ............. 05

SOMEWHERE ELSE (PLEASE SPECIFY) . . 06

 

 |__|__| |__|__|

AT HOME ........................... 07
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 11 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ...................... 01

VISIT BY CASEWORKER ............... 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES ................................ 01

NO ................................. 00

DON’T KNOW ........................ -1

DOESN’T WORK ..................... -4

D4g.-

D4i. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 12 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. You didn’t want to get food from family, friends, government

programs, or other sources? ........................ 01 00

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

______________________________________________

______________________________________________

 |__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 13 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to the

food stamp office? ................................... 01 00 --

b. Did you have to go to the food stamp office even though your

health or disability made it difficult? ...................... 01 00 --

c. Was it difficult for you to take time off from work to apply for

food stamp benefits? ................................. 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? .......................................... 01 00 -4

e. Did you have to arrange for care of someone in your home so

that you could go to the food stamp office? ................ 01 00 --

f. Did you have to wait a long time to be served at the food stamp

office? ............................................ 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ........... 01 00 --

h. Do you think the application form was too long and

complicated? ....................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? .......................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? ........................................ 01 00 --

k. Did you feel embarrassed having to apply for food stamps? ... 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ..................... 01

NO ...................... 00 ! SKIP TO D8

D7b. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 14 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ............................ 01

NO ............................. 00

DON’T KNOW .................... -1 SKIP TO D10

REFUSED ....................... -3

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

DIDN’T THINK ELIGIBLE ........... 01

BENEFIT TOO LOW ............... 02

APPLICATION TOO

TIME-CONSUMING ............... 03

APPLICATION FORM TOO

COMPLICATED ................... 04

APPLICATION TOO PERSONAL ..... 05

TOO MUCH PAPERWORK .......... 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ................... 07

NOT TREATED WELL BY STAFF .... 08

STIGMA/EMBARRASSMENT/PRIDE . . 09

HEALTH/MOBILITY PROBLEMS ..... 10

LANGUAGE/LITERACY PROBLEMS . . 11

MY SITUATION CHANGED ......... 12

TRANSPORTATION PROBLEM ...... 13

HARD TO GET TIME OFF WORK .... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ............. 15

OTHER (SPECIFY) ................ 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 15 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................. 01

NO .................................. 00 

SKIP TO D12

DON’T KNOW ......................... -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them but did not use any

of them.

YES ................................. 01

NO .................................. 00 

SKIP TO D17

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 16 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP

BENEFITS ............................ 01

NOT TREATED WELL IN FOOD STORES ... 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ............... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS . . 04

NOT TREATED WELL BY OFFICE/

PROGRAM ........................... 05

TOO HARD TO PICK UP COUPONS/

STAMPS ............................. 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN .......................... 07

BENEFIT AMOUNT WAS TOO SMALL ..... 08

DID NOT NEED FOOD STAMPS .......... 09

OTHER (SPECIFY) ..................... 10

 

 |__|__| |__|__|

D14.-

D16. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 17 (REV--1/16/98--WP70) 12/16/99 1:16 PM

(PLEASE SPECIFY):

 |__|__| |__|__|

D17. Now I would like to talk to you about some things that may have helped you

decide to use food stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. Did you receive a lot of help with the

application? ........................ 01 00

b. Did other family members or friends 

encourage you to get food stamp 

benefits? .......................... 01 00

c. Do you feel it’s OK to receive food stamp

benefits because you pay taxes? ........ 01 00

d. Do you feel you couldn’t get by on your own

without food stamp benefits? ........... 01 00

e. Are you uncomfortable getting food 

from family, friends, charities, or other 

programs? ......................... 01 00

D18. Are there other circumstances that I haven’t mentioned that helped you decide to

use food stamp benefits?

YES .................................. 01

NO ................................... 00

D19. INTERVIEWER: CHECK QUESTION D17a. DID THEY RECEIVE A LOT OF

HELP WITH THE APPLICATION?

YES .................................. 01

NO ................................... 00 ! SKIP TO F0
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 18 (REV--1/16/98--WP70) 12/16/99 1:16 PM

D20. You said you received a lot of help with the application, what type of help did you

receive? RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D21. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
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E. NO SECTION E

F. RECEIPT OF FOOD ASSISTANCE

F0. INTERVIEWER: IS ANYONE IN THIS HOUSEHOLD AGE 60 OR OLDER?

YES .................................. 01

NO ................................... 00 ! SKIP TO F1a

F1. During the past 12 months, did (you/anyone) in the household ever receive free

or reduced-cost meals for the elderly either at a facility or delivered to your

home?

PROBE: By facility we mean places such as a senior center or community

center or some other special place with a meal program.

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F1a. INTERVIEWER: ARE THERE ANY CHILDREN UNDER 18 IN THE

HOUSEHOLD?

YES ................................. 01

NO CHILDREN ........................ 00 ! SKIP TO F5

F2. During the past 12 months, did any children in the household ever receive free or

reduced-cost meals at a day-care or Head Start program?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

CHILD/CHILDREN DO NOT ATTEND

DAY CARE PROGRAM .................. -4
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F3. Not counting meals at Head Start or daycare programs, during the past 12

months, did any children in the household ever receive free or reduced-cost

lunches at school?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

CHILD/CHILDREN DO NOT

ATTEND SCHOOL ..................... -4! SKIP TO F5

F4. During the past 12 months, did any children in the household ever receive free or

reduced-cost breakfasts at school?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F5. INTERVIEWER: CHECK QUESTION A3: IS ANYONE IN THIS

HOUSEHOLD EITHER UNDER AGE 6 OR A WOMAN

UNDER 45 YEARS OF AGE?

YES .................................. 01

NO ................................... 00 ! SKIP TO F7

F6. During the past 12 months, did any (women/women or children/children) in this

household ever get food through the WIC program?

PROBE: By WIC we mean the U.S. Department of Agriculture’s Special

Supplemental Nutrition Program for Women, Infants, and Children,

which provides food packages to women, infants, and young children.

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

NO WOMEN OR CHILDREN .............. -4
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(SPECIFY PROGRAM):

 

 |__|__| |__|__|

F7. During the past 12 months, did (you/anyone in the household) ever get food, or

vouchers to buy food, from any (other) kind of program?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F8. In the last 12 months, did you (or other adults in your household) ever get food or

borrow money for food from friends or relatives?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F9. In the last 12 months, did you (or other adults in your household) ever get

emergency food from a church, a food pantry, or food bank?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F10. In the last 12 months, did you (or other adults in your household) ever eat any

meals at a soup kitchen?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1
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Where?

 

 |__|__| |__|__|

F10a. In the last 12 months, did you (or other adults in the household) ever receive free

or reduced-price meals at work?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F11. Some people are able to get food from their own garden or farm, or from hunting

or fishing. During the last 12 months, did you (anyone in the household) ever get

food from . . .

YES NO

a. Your own vegetable garden? ............................ 01 00 

b. Meat, poultry, or eggs from animals you raise? .............. 01 00 

c. Meat or fish from hunting or fishing? ...................... 01 00 

F11a. In the last 12 months, did you (or other adults in your household) ever get free

food from any source we haven’t already mentioned?

PROBE: Please include any free meals or groceries that you receive from any

person or source that we haven’t already mentioned.

YES .................................. 01

NO ................................... 00

F12. NO QUESTION THIS VERSION.
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INTERVIEWER: IF RESPONSE CODE IS FOLLOWED BY AN ASTERISK (*),

CIRCLE THE QUESTION NUMBER.

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G2. “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get

more.” Was that often true, sometimes true or never true for you in the last 12

months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G3. “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes or

never true for you in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
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G4. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G8

G5. (I/We) relied on only a few kinds of low-cost foods to feed (my/our) (child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G6. “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we)

couldn’t afford that.” Was that often, sometimes, or never true for (you/your

household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G7. “(My/Our child was/The children were) not eating enough because (I/we) just

couldn’t afford enough food.” Was that often, sometimes, or never true for

(you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
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G8. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

21 AND 22? IS THE RESPONSE TO G1, G2, G3, G5, OR G6 “OFTEN TRUE”

(01) OR “SOMETIMES TRUE” (02)?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G10

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G10. In the last 12 months, did you ever eat less than you felt you should because there

wasn’t enough money to buy food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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G11. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t

afford enough food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G12. In the last 12 months, did you lose weight because you didn’t have enough

money for food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01 *

NO .................................. 00 

 SKIP TO G14

DON’T KNOW ......................... -1

G13a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G14. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1
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G15. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

23 AND 24? IS THE RESPONSE TO G7 “OFTEN TRUE” (01) OR

“SOMETIMES TRUE” (02) OR IS THERE A “YES” RESPONSE TO G11, G12 OR

G13?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G16. The next questions are about children living in the household who are under 18

years old.

in the last 12 months, since (CURRENT MONTH) of last year, did you ever cut

the size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G17. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals

because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 SKIP TO G18

DON’T KNOW ......................... -1

G17a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1
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G18. In the last 12 months, (was your child/were the children) ever hungry but you just

couldn’t afford more food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G19. In the last 12 months, did (your child/any of the children) ever not eat for a whole

day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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H. EMPLOYMENT HISTORY

H1. Including yourself, which people in your household work at a job for pay? RECORD NAMES AT H1.

NONE ..................................... 00 ! SKIP TO J1

HOUSEHOLD NAMES RECORDED BELOW ...... 01

H2. How many hours per week (does NAME/do you)usually work for pay? RECORD BELOW OPPOSITE

PERSONS NAME. PROBE: Your best estimate would be fine.

INTERVIEWER: IF RESPONDENT UNABLE TO TELL YOU USUAL HOURS WORKED PER

WEEK, ASK “HOW MANY HOURS DID YOU WORK LAST WEEK OR DURING

THE MOST RECENT WEEK YOU WORKED IF YOU DID NOT WORK LAST

WEEK?”

H3. How much (does NAME/do you) earn on this job, before taxes and any other deductions are taken out?

RECORD BELOW FOR EACH PERSON.

INTERVIEWER: IF RESPONDENT RECEIVES TIPS AS PART OF EARNINGS, ASK

RESPONDENT TO REPORT WHAT HE OR SHE EARNED LAST WEEK (OR

MOST RECENT WEEK WORKED IF NOT LAST WEEK) INCLUDING TIPS, AND

RECORD AS “SALARY PER WEEK.”

PROBE: What is (NAME’S/YOUR) gross pay?

H1 H2 H3

Name Hours Hourly OR Salary Per Salary Basis

Per Week Wage

1 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

2 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

3 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

4 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
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5 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
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H4. INTERVIEWER: LOOK AT QUESTIONS H1 AND H2. SELECT PERSON

WHO WORKS GREATEST NUMBER OF HOURS PER

WEEK.

NAME: 

CODER: PERSON # FROM A1: |___|___|

H5. Now I’m going to ask you some questions about (your/NAME’S) job.

What is (your/NAME’S) job title?

FOR EXAMPLE: Retail sales person, clerk, waiter, cook.

IF MORE THAN ONE JOB, PROBE FOR THE JOB PERSON CURRENTLY

SPENDS MOST TIME AT.

 |__|__| |__|__|

H6. What are (your/NAME’S) main duties as (a/an) (JOB TITLE FROM H5)?

PROBE: What are (your/NAME’S) responsibilities or activities?

What (do you/does NAME)spend the most time doing?

 |__|__| |__|__|

H7. How long (have you/has NAME) been working at this job?

IF MORE THAN ONE JOB, PROBE FOR JOB PERSON CURRENTLY

SPENDS MOST TIME AT.

RECORD TO THE NEAREST YEAR. IF LESS THAN ONE YEAR, RECORD

MONTHS.

|___|___| YEARS OR |___|___| MONTHS
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H8. How likely is it that (you/NAME) will be working at this job three months from

now? Would you say it is very likely, somewhat likely, or not likely at all?

VERY LIKELY .......................... 01

SOMEWHAT LIKELY .................... 02

NOT LIKELY AT ALL .................... 03

DON’T KNOW .......................... -1

H9. Do you think (you/NAME) will be earning more, the same, or less three months

from now?

MORE ................................ 01

SAME ................................ 02

LESS ................................. 03

DON’T KNOW .......................... -1

H10. Including (your/NAME’s) present job, over the past 12 months, how many

different paid jobs (have you/has NAME) had? Please include all part-time and

full-time jobs held for at least two weeks.

CIRCLE ONE

ONE ................................ 01

TWO ................................ 02

THREE .............................. 03

FOUR ............................... 04

FIVE OR MORE ....................... 05

DON’T KNOW ......................... -1
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H11a. During the past 12 months, were there times when (you were/NAME was) not

working for pay?

YES ................................. 01

NO .................................. 00 ! SKIP TO J1

H11b. About how many months (were you/was NAME) not working for pay?

CIRCLE ONE

NONE ............................... 00

LESS THAN ONE MONTH ............... 01

BETWEEN 1 AND 3 MONTHS ............ 02

BETWEEN 4 AND 6 MONTHS ............ 03

BETWEEN 7 AND 9 MONTHS ............ 04

BETWEEN 10 AND 12 MONTHS .......... 05

DON’T KNOW ......................... -1
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I. NO SECTION I

J. SOCIAL SUPPORTS

J1. How long have you lived in your neighborhood?

IF LESS THAN ONE YEAR, ENTER “00” FOR YEARS AND RECORD

NUMBER OF MONTHS.

|___|___| / |___|___|

YEARS MONTHS

OR

SINCE |___|___| 19 |___|___|

MONTH YEAR

J2. NO QUESTION THIS VERSION.

J3. How close do you live to your nearest relative who does not live with you? Do

you live less than 30 minutes away, 30 minutes to 2 hours away, or more than 2

hours away?

CIRCLE ONE

LESS THAN 30 MINUTES AWAY .......... 01

30 MINUTES TO 2 HOURS AWAY ......... 02

MORE THAN 2 HOURS AWAY ............ 03

NO LIVING CHILDREN OR RELATIVES ..... -4
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K. INCOME AND EXPENSES

K1. Which of the following best describes where you live now . . .

A place you own, ....................... 01

A place you rent, ....................... 02 ! GO TO K5

A place where you live rent free, ........... 03 

GO TO K6

Or someplace else? (SPECIFY) ........... 04

 

K2. What is your monthly mortgage payment?

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

K3. (Do you/Does your household) make a separate home insurance payment?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

K4. (Do you/Does your household) pay a separate property tax bill?

YES ................................. 01

NO .................................. 00 SKIP TO K6

DON’T KNOW ......................... -1
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K5. What is your monthly rent payment? Please tell me only the amount that you and

members of your household pay out-of-pocket.

PROBE: Do not include any rent subsidies that your household receives from

any program to pay part of the rent costs.

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

K5a. (Do you/Does your household) pay separate heating or air-conditioning costs?

YES ................................. 01

NO .................................. 00

K6. INTERVIEWER: CHECK GRID A1 THROUGH A3. HOW MANY PEOPLE

ARE IN HOUSEHOLD?

ONE ................................. 01 ! SKIP TO K7b

MORE THAN ONE ...................... 02

K6a. Last month, did (you/your household) pay for the care of children or other

dependents so that someone in your household could go to work, school, or a

training program?

YES ................................. 01

NO .................................. 00 ! SKIP TO K7b

DON’T KNOW ......................... -1

K6b. How much did (you/your household) pay out-of-pocket last month?

$ |___|, |___|___|___|

DON’T KNOW ......................... -1
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K7. NO QUESTION THIS VERSION.

K7a. NO QUESTION THIS VERSION.

K7b. Is anyone in your household disabled? Please count as disabled persons who

receive SSI benefits because of a disability, social security disability checks,

disability retirement pensions, railroad retirement disability payments, or veteran

disability benefits.

YES ................................. 01 ! SKIP TO K8

NO .................................. 00

DON’T KNOW ......................... -1

K7c. Is there anyone in your household who is age 60 or older?

YES ................................. 01

NO .................................. 00 

SKIP TO K10

DON’T KNOW ......................... -1

K8. Last month, did (you/your household) pay health insurance premiums or

payments to belong to an HMO?

YES ................................. 01

NO .................................. 00 

SKIP TO K9

DON’T KNOW ......................... -1

K8a. How much did (you/your household) pay last month. Please tell me only the

amount that you and members of your household pay out-of-pocket.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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K8b. NO QUESTION THIS VERSION.

K9. Now think about the people in your household who are disabled or age 60 or

older. Last month, how much were their out-of-pocket medical expenses? 

Include doctor and hospital bills, prescription drugs, lab tests or X-rays, and any

other medical expenses you paid out-of-pocket. Please exclude anything for

which you will be reimbursed.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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INTERVIEWER: CHECK GRID A1 THROUGH A3: IF RESPONDENT LIVES ALONE, DON’T ASK

K12, K13, OR K14. THAT IS, ALWAYS SKIP TO NEXT QUESTION IN K10 AFTER

COMPLETING K11 FOR EACH INCOME SOURCE.

K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

1. CO: Colorado Works; [STATE WELFARE NAME]/ DON’T

MA: Transitional Aid to Temporary Assistance for Needy NAME AMOUNT KNOW

Families with Dependent Families (TANF)?

Children; __________________ $ |___|,|___|___|___| -1

MN: MFIP Minnesota’s $ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

Family Investment __________________ $ |___|,|___|___|___| -1 

Program; DON’T NO ......... 00 6 GO TO K10.2

NC: Work First Benefits KNOW. . .-1 ! GO TO K12 __________________

PA/TX: Temporary $ |___|,|___|___|___| -1 

Assistance for Needy __________________

Families (TANF)?

YES ...... 01

NO ....... 00 6 ASK K12

$ |___|,|___|___|___| -1 

2. General Assistance, General Assistance, general relief, DON’T

general relief, or welfare? or welfare? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.3 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________

__________________ 

 

$ |___|,|___|___|___| -1

$ |___|,|___|___|___| -1 

3. Social Security checks Social Security checks from the DON’T

from the government? government? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.4 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

4. Other retirement benefits Other retirement benefits (that are DON’T

(that are not Social not Social Security) such as a NAME AMOUNT KNOW

Security) such as a government or private pension or

government or private annuity? __________________ $ |___|,|___|___|___| -1

pension or annuity? 

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.5 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

H:\PROJECT\8305\012\Ques\WP-LONG.Q6 40 (REV--1/16/98--WP70) 12/16/99 1:16 PM

5. SSI or Supplemental SSI or Supplemental Security DON’T

Security Income from the Income from the federal, state, or NAME AMOUNT KNOW

federal, state, or local local government?

government? __________________ $ |___|,|___|___|___| -1

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.6 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

H:\PROJECT\8305\012\Ques\WP-LONG.Q6 41 (REV--1/16/98--WP70) 12/16/99 1:16 PM

6. Veteran's benefits? Veteran's benefits? DON’T

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01

DON’T NO ......... 00 6 GO TO K10.7 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

NAME AMOUNT KNOW

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

7. Unemployment Insurance Unemployment Insurance or DON’T

or workman's workman's compensation NAME AMOUNT KNOW

compensation benefits? benefits?

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.8

KNOW. . .-1 ! GO TO K12 __________________

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________

$ |___|,|___|___|___| -1 

$ |___|,|___|___|___| -1 

8. Any child support Any child support payments or DON’T

payments or alimony? alimony? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12

DON’T 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K10.9 __________________ $ |___|,|___|___|___| -1 

YES ......... 01 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

9. Payments from roomers or Payments from roomers or DON’T

boarders? boarders? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.10 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 

10. Financial support from Financial support from friends or DON’T

friends or family? family? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.11 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

H:\PROJECT\8305\012\Ques\WP-LONG.Q6 42 (REV--1/16/98--WP70) 12/16/99 1:16 PM

11. Any other income such as Any other income such as income DON’T

income from business or from business or prizes? NAME AMOUNT KNOW

prizes?

YES ..... 01 ! (SPECIFY)

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 __________________ $ |___|,|___|___|___| -1 

DON’T __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K15

YES ......... 01 ! SPECIFY

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 43 (REV--1/16/98--WP70) 12/16/99 1:16 PM

K15. Do you (or does anybody in your household) own a car, truck, van, or

motorcycle? Please include any cars, trucks, vans, or motorcycles 

that you’re making payments on.

YES .................................. 01

NO ................................... 00 ! SKIP TO K18

K16. What (is/are) the year(s), make(s), and model(s) of the car(s), truck(s), van(s), or

motorcycle(s)?

PROBE: Please include any vehicle owned by a household members.

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

DON’T KNOW ......................... -1 ! ASK K17

SKIP TO K18

K17. INTERVIEWER: IF YEAR, MAKE OR MODEL ARE UNKNOWN, ASK:

What is the approximate value of each vehicle owned by

household members?

Vehicle 1: $ ________________________

Vehicle 2: $ ________________________

Vehicle 3: $ ________________________
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 44 (REV--1/16/98--WP70) 12/16/99 1:16 PM

K18. (Including yourself, is anyone in your household/Are you) legally required to pay

child support?

YES ................................. 01

NO .................................. 00 ! SKIP TO L2

K19. In total, how much child support (was paid by all members of your household/did

you pay) last month?

$ |___|___|,|___|___|___| ! SKIP TO L2

DON’T KNOW .......................... -1

REFUSED ............................. -3

K20. Would you tell me which of the following ranges best describes the total amount

of child support paid last month?

More than $250 ......................... 01 ! SKIP TO K22

Exactly $250 ........................... 02 ! SKIP TO L2

Less than $250 ......................... 03

DON’T KNOW/REFUSED ................. -3 ! SKIP TO L2

K21. Was it . . .

$50 or less, ............................ 01

Between $51 and $100, .................. 02

Between $101 and $150, ................. 03 SKIP TO L2

Between $151 and $200, ................. 04

Or, between $201 and $250? .............. 05

DON’T KNOW/REFUSED ................. -3
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 45 (REV--1/16/98--WP70) 12/16/99 1:16 PM

K22. Was it . . .

Between $250 and $300, ................. 01

Between $301 and $350, ................. 02

Between $351 and $400, ................. 03

Between $401 and $450, ................. 04

Or, over $450? ......................... 05

DON’T KNOW/REFUSED ................. -3
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 46 (REV--1/16/98--WP70) 12/16/99 1:16 PM

L. DEMOGRAPHIC INFORMATION

L1. NO QUESTION THIS VERSION.

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ................................ 01

FEMALE ............................. 00

L3. Are you now . . .

Married, .............................. 01

Living with someone as married, ........... 02

Widowed, ............................. 03

Divorced, ............................. 04

Separated, ............................ 05

Or have you never been married? .......... 06
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 47 (REV--1/16/98--WP70) 12/16/99 1:16 PM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ......................... 01

SECOND GRADE ....................... 02

THIRD GRADE ......................... 03

FOURTH GRADE ....................... 04

FIFTH GRADE ......................... 05

SIXTH GRADE ......................... 06

SEVENTH GRADE ...................... 07

EIGHTH GRADE ........................ 08

NINTH GRADE ......................... 09

TENTH GRADE ........................ 10

ELEVENTH GRADE ..................... 11

TWELFTH GRADE ...................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) ... 13

GED ................................. 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE .......................... 15

SOME COLLEGE ....................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE .............................. 17

OTHER (SPECIFY) ...................... 18

 

 |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

REFUSED ............................. -3
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L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7. Is everyone in your household a U.S. citizen?

YES .................................. 01 ! SKIP TO L8

NO ................................... 00

L7a. Is anyone in your household a U.S. citizen?

YES .................................. 01

NO ................................... 00

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
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M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT .......................... 01

GOOD ............................... 02

FAIR ................................ 03

POOR ............................... 04

M2. Did the respondent seem to have any trouble understanding English?

YES ................................. 01

NO .................................. 00

M3. Were there any questions that the respondent complained about?

YES ................................. 01

NO .................................. 00 ! SKIP TO M4
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 50 (REV--1/16/98--WP70) 12/16/99 1:16 PM

M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\WP-LONG.Q6 51 (REV--1/16/98--WP70) 12/16/99 1:16 PM

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7--LAVENDER QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 12:10 PM

OMB No.: 0584-0486

Expiration Date: 11/98

ELDERLY NONPARTICIPANT

SHORT INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 2 (REV--1/21/98--WP70) 12/16/99 12:10 PM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Elderly Nonparticipant--Short

A. HOUSEHOLD COMPOSITION

A1s. How many people in your household are 60 years of age or older? By household

I mean yourself and the people who currently live with you and share food with

you.

PROBE: Include any persons who live with you more than half time.

|___|___|

A2s. Including yourself, how many people in your household are under 18 years of

age?

|___|___|

A3s. Including yourself, how many people in your household currently work at a job for

pay?

|___|___|

NONE ............................... 00 ! SKIP TO C1

A4s. Do you work at a job for pay?

YES ................................. 01

NO .................................. 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 3 (REV--1/21/98--WP70) 12/16/99 12:10 PM

B. NO SECTION B

C. FSP PARTICIPATION HISTORY

C1. Have you received food stamp benefits in the past 3 years?

YES ................................. 01

NO .................................. 00 ! SKIP TO D1

C2.-

C2a. NO QUESTIONS THIS VERSION.

C3. When was the last time you received food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

C3a. INTERVIEWER: IS DATE MORE THAN THREE YEARS AGO?

YES ................................. 01 ! SKIP TO D1

NO .................................. 00

DON’T KNOW ......................... -1

C4. How did you get your food stamp benefits in (DATE FROM C3)? Did you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ........................... 01

EBT CARD ........................... 02
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C4a. What was the amount of food stamp benefits you received in (DATE

FROM C3)?

$ |___|, |___|___|___|

DON’T KNOW ......................... -1

C5. Did you stop receiving food stamp benefits in (DATE FROM C3) because you

were notified that you were not eligible?

YES ................................. 01 ! SKIP TO C13a

NO .................................. 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 5 (REV--1/21/98--WP70) 12/16/99 12:10 PM

C6. Why did you stop participating in the food stamp program in (DATE FROM C3)? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

NOT WORTH THE EFFORT FOR

THE AMOUNT OF BENEFITS ............ 01

NO LONGER NEEDED FOOD STAMP

BENEFITS ............................ 02

EMBARRASSED USING FOOD STAMP

BENEFITS ............................ 03

THOUGHT NO LONGER ELIGIBLE ........ 04

THOUGHT SITUATION WOULD

IMPROVE ............................ 05

HARD TO GET TO FOOD STAMP OFFICE . . 06

PROCESS OF RECEIVING FOOD

STAMP BENEFITS IS TOO LONG

OR COMPLICATED .................... 07

HAD TO ANSWER TOO MANY

PERSONAL QUESTIONS ................ 08

FAMILY MEMBERS DISAPPROVED

OF MY/OUR RECEIVING FOOD

STAMP BENEFITS ..................... 09

DO NOT LIKE TO RELY ON

GOVERNMENT ASSISTANCE ............ 10

OTHER PEOPLE NEEDED THEM MORE ... 11

NOT TREATED WELL BY STAFF ......... 12

OFFICE IS VERY UNPLEASANT .......... 13

OFFICE IN AN UNSAFE

NEIGHBORHOOD ..................... 14

OTHER (SPECIFY) ..................... 15

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 6 (REV--1/21/98--WP70) 12/16/99 12:10 PM

C7.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO C13c

REFUSED ............................ -3

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 7 (REV--1/21/98--WP70) 12/16/99 12:10 PM

SKIP TO C13c

C13a. Why were you found ineligible? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

C13b. NO QUESTION THIS VERSION.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 8 (REV--1/21/98--WP70) 12/16/99 12:10 PM

C13c. When you received food stamps in the past three years, did you ever do things

so that people will not find out you receive food stamp benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ................................. 01

NO .................................. 00

C14. Now I’m going to read some statements about experiences with food stamp

benefits over the past three years.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in 

stores, were you sometimes treated

disrespectfully by either employees or

customers? ........................ 01 00

b. Were you embarrassed to use food stamp

benefits? .......................... 01 00

c. Did you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Did you feel that you really needed food

stamp benefits to make it through the

month? ............................ 01 00

e. Did you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Did you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Did food stamp office staff ever treat you

disrespectfully? ..................... 01 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 9 (REV--1/21/98--WP70) 12/16/99 12:10 PM

C15. Did you experience other difficulties with food stamp benefits that you have not

already mentioned? Please do not include any difficulties you had applying, we

will ask about this later.

YES ................................. 01

NO .................................. 00 ! SKIP TO D1

C16. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 10 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D. HISTORY OF APPLICATIONS

D1. Have you applied for food stamp benefits in the past 3 years? By applied I mean

have you at least completed a new application form?

YES ................................. 01

NO .................................. 00 

SKIP TO D14

DON’T KNOW ......................... -1

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH/YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ................................. 01 ! SKIP TO D4c

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 11 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ........................ 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ............... 01

AT SSI OFFICE ........................ 02

AT A SENIOR CENTER ................. 03 SKIP TO D4g

AT A HOSPITAL ....................... 04

AT A HOUSING COMPLEX .............. 05

SOMEWHERE ELSE (PLEASE SPECIFY) . . 06

 

 |__|__| |__|__|

AT HOME ............................ 07
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D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ....................... 01

VISIT BY CASEWORKER ............... 02

D4f. NO QUESTION THIS VERSION.

D4g. The last time you applied, did you have a lot of help with the application?

YES ................................. 01

NO .................................. 00 

SKIP TO D5

DON’T KNOW ......................... -1

D4h. What type of help did you receive? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 13 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D4i. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|

D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

|__|__| |__|__|

01 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 14 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D5a.-

D6. NO QUESTIONS THIS VERSION.

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ................................. 01

NO .................................. 00 ! SKIP TO D8
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 15 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D7b. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO D10

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 16 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 17 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................. 01

NO .................................. 00 

SKIP TO D12

DON’T KNOW ......................... -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible to receive food stamp benefits, why were you found ineligible? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 18 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them but did not use any

of them.

YES ................................. 01

NO .................................. 00 

SKIP TO E1

DON’T KNOW ......................... -1

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP

BENEFITS ............................ 01

NOT TREATED WELL IN FOOD STORES . . 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ............... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS . . 04

NOT TREATED WELL BY OFFICE/

PROGRAM ........................... 05

TOO HARD TO PICK UP COUPONS/

STAMPS ............................. 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN .......................... 07

BENEFIT AMOUNT WAS TOO SMALL ..... 08

DID NOT NEED FOOD STAMPS .......... 09

OTHER (SPECIFY) ..................... 10

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 19 (REV--1/21/98--WP70) 12/16/99 12:10 PM

GO TO E1

D14. Have you contacted the food stamp office to ask about food stamp benefits in

the past 3 years?

YES ................................. 01

NO .................................. 00 ! SKIP TO E1

D15.-

D16b. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 20 (REV--1/21/98--WP70) 12/16/99 12:10 PM

D16c. Why didn’t you complete an application form at that time? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|

D17.-

D21. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 21 (REV--1/21/98--WP70) 12/16/99 12:10 PM

THIS PAGE INTENTIONALLY BLANK
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 22 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E. NON-PARTICIPATION

Now I would like to talk to you about the reasons you currently do not use food stamps.

E1. E2. E4.

Is this an important reason

you don’t use food stamp

benefits?

YES NO KNOW YES NO KNOW REASON

DON’T DON’T IMPORTANT

MOST

a. Do you know where to go or who to

contact to apply for food stamp SKIP 

benefits? ...................... 01 !TO E1b 00 -1 01 00 -1 01

b. Do you think you are currently eligible SKIP 

for food stamp benefits? .......... 01 !TO E1c 00 -1 01 00 -1 02

c. Do you think it would be hard to get SKIP SKIP 

to the food stamp office? .......... 01 00 ! TO E1d -1 !TO E1d 01 00 -1 03

d. Do you think the application process SKIP SKIP 

is too long and complicated? ....... 01 00 ! TO E1e -1 !TO E1e 01 00 -1 04

e. Do you think you would have to

answer questions that are too

personal when applying for food SKIP SKIP 

stamp benefits? ................. 01 00 ! TO E1f -1 ! TO E1f 01 00 -1 05

f. Do you think you would feel

embarrassed applying for SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1g -1 !TO E1g 01 00 -1 06

g. Do you think you would be eligible for

only a small amount of food stamp SKIP SKIP 

benefits? ...................... 01 00 ! TO E1h -1 !TO E1h 01 00 -1 07

h. Can you get by on your own without SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1i -1 ! TO E1i 01 00 -1 08

i. Do you feel that others need food SKIP SKIP 

stamp benefits more than you do? . . 01 00 ! TO E1j -1 ! TO E1j 01 00 -1 09

j. Would you feel embarrassed using SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1k -1 !TO E1k 01 00 -1 10

k. Would you dislike relying on SKIP SKIP 

government assistance? .......... 01 00 ! TO E1l -1 ! TO E1l 01 00 -1 11

l. Would other family members or

friends discourage you from using SKIP SKIP 

food stamp benefits? ............. 01 00 !TO E1m -1 !TO E1m 01 00 -1 12

m. Do you think that staff at the food

stamp office would treat you SKIP SKIP 

disrespectfully? ................. 01 00 ! TO E1n -1 !TO E1n 01 00 -1 13

n. Do you think that the food stamp

office would be very unpleasant or SKIP SKIP 

you would not be safe? ........... 01 00 ! TO E1o -1 !TO E1o 01 00 -1 14

o. Do you think your need for food SKIP SKIP 

stamp benefits is only temporary? ... 01 00 ! TO E1p -1 !TO E1p 01 00 -1 15
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 23 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

p. Are there other important reasons

why you do not use food stamp

benefits that we have not just SKIP SKIP

mentioned? ....................

RECORD VERBATIM BELOW:

01 00 ! TO E3 -1 ! TO E3 01 00 -1 16
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 24 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E3. INTERVIEWER: HOW MANY “YESES” ARE CIRCLED IN QUESTION E2?

NONE ................................ 00 

SKIP TO E5

ONE ................................. 01

MORE THAN ONE ...................... 02

E4. Of all the reasons you gave (READ IMPORTANT REASONS FROM E2 IF

NECESSARY), what is the most important reason you do not currently use food

stamp benefits? RECORD IN COLUMN MARKED E4.

E5. INTERVIEWER: WAS THE RESPONSE TO E1b “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E7

E6. You said you think you are currently eligible for food stamp benefits. How much

in food stamp benefits do you think you would qualify for each month? Your best

estimate is fine.

CIRCLE ONE RESPONSE

$10 OR LESS ......................... 01

BETWEEN $11 AND $25 ................ 02

BETWEEN $26 AND $50 ................ 03

BETWEEN $51 AND $100 ............... 04

BETWEEN $101 AND $150 .............. 05

BETWEEN $151 AND $200 .............. 06

BETWEEN $201 AND $300 .............. 07

MORE THAN $300 ..................... 08

DON’T KNOW ......................... -1

GO TO E9
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 25 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E7. You said you think you are not currently eligible for food stamp benefits. Why do

you think that you are not eligible to receive food stamp benefits? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DO NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

E8. Do you think you are currently ineligible because you were told by someone at

the food stamp office that you are ineligible?

YES ................................. 01

NO .................................. 00 ! SKIP TO E8b

E8a. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN THE LAST MONTH .............. 01

WITHIN THE LAST 3 MONTHS ........... 02

WITHIN THE LAST YEAR ............... 03

MORE THAN ONE YEAR AGO ........... 04

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 26 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E8b. Were you told by someone at another program that you are ineligible for food

stamp benefits?

YES ................................. 01 ! SKIP TO E9

NO .................................. 00

DON’T KNOW ......................... -1

E8c. Do you think you are ineligible because you know someone like you who is

ineligible?

YES ................................. 01

NO .................................. 00

E9. INTERVIEWER: WAS THE RESPONSE TO E1c “YES”?

YES ................................ 01

NO ................................. 00 ! SKIP TO E11

E10. You said you think it would be hard to get to the food stamp office. Is this . . .

YES NO

a. Because it is difficult or expensive to get transportation? .... 01 00

b. Because of difficulties you have getting around? .......... 01 00

c. Because of difficulties you would have taking time off

work? ........................................... 01 00

d. Because you would lose pay going to the food stamp

office? ........................................... 01 00

e. Because you would have to pay for someone to take

care of someone in your home? ....................... 01 00

f. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ................................

|__|__| |__|__|

01 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 27 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E11. INTERVIEWER: WAS THE RESPONSE TO E1d “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12. You think the application process would be too long and complicated. Is

this . . .

YES NO

a. Because you think you would have to wait a long time

to be served? ..................................... 01 00

PROBE: A long time from your point of view.

b. Because you think the application form is too long and

complicated? ...................................... 01 00

c. Because you think it would be difficulty to get all the necessary

paperwork? ....................................... 01 00

d. Because of some other reason I haven’t mentioned? .......

(PLEASE SPECIFY) ................................

|__|__| |__|__|

01 00

E12a. INTERVIEWER: WAS THE RESPONSE TO PART “a” OF E12“YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12b. You said you would have to wait a long time to be served. How long do you think

you would have to wait? Would it be . . .

15 minutes or less? ...................... 01

16 to 30 minutes? ....................... 02

31 minutes to one hour? .................. 03

Or, more than one hour? .................. 04

DON’T KNOW .......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 28 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E13. INTERVIEWER: WAS THE RESPONSE TO E1e “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E15

E14. You said you would have to answer questions that were too personal. What type

of questions do you feel are too personal?

CIRCLE ALL THAT APPLY

WHO LIVES IN HOUSEHOLD ............. 01

CITIZENSHIP .......................... 02

DISABILITIES .......................... 03

RESOURCES/ASSETS .................. 04

INCOME .............................. 05

MEDICAL EXPENSES ................... 06

DEPENDENT-CARE EXPENSES ........... 07

SHELTER EXPENSES ................... 08

CHILD SUPPORT PAYMENTS ............ 09

OTHER (SPECIFY) ...................... 10

 

 |__|__| |__|__|

E15. INTERVIEWER: WAS THE RESPONSE TO E1g “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E17

E16. You said you think you are eligible for only a small amount of food stamp

benefits.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 29 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E16a. Were you told by someone at a food stamp office that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01

NO ................................ 00 

 SKIP TO E16c

DON’T KNOW ....................... -1

E16b. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN LAST MONTH ................ 01

WITHIN LAST 3 MONTHS ............. 02

WITHIN THE LAST YEAR ............. 03

MORE THAN ONE YEAR AGO ......... 04

DON’T KNOW ....................... -1

GO TO E17

E16c. Were you told by someone at another program that you were eligible for only a

small amount of benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

E16d. Do you think that you would receive only a small amount of benefits because you

know someone like you who receives only a small amount of benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 30 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

E17. INTERVIEWER: WAS THE RESPONSE TO E1n “YES”?

YES ............................... 01

NO ................................ 00 ! SKIP TO E19

E18. You thought the food stamp office would be very unpleasant or you would not be

safe? Is this . . .

YES NO

a. Because the inside of the building would be

unpleasant? ................................ 01 00

b. Because you wouldn’t like waiting with the other

applicants? ................................. 01 00

c. Because the office would be in an unsafe

neighborhood? .............................. 01 00

d. Because of something else? (SPECIFY) ......... 01 00

|__|__| |__|__|

E19. Do you agree with the statement made by some people that “its OK to receive

food stamp benefits if you pay taxes”?

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 31 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

F. NO SECTION F

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G2.-

G4. NO QUESTIONS THIS VERSION.

G4s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G9

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 32 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

G6.-

G8. NO QUESTIONS THIS VERSION.

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G13

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G10.-

G12. NO QUESTIONS THIS VERSION.

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 

 SKIP TO G14s

DON’T KNOW ......................... -1

G14. NO QUESTION THIS VERSION.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 33 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

G14s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO L1

G15. NO QUESTION THIS VERSION.

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G17.-

G19. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 34 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

H. NO SECTION H

I. NO SECTION I

J. NO SECTION J

K. NO SECTION K

L. DEMOGRAPHIC INFORMATION

L1. Now, I have just a few final questions.

Can you tell me your age?

|___|___| / |___|___| / 19 |___|___|

MONTH DAY YEAR

OR |___|___| YEARS OLD

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................... 01

FEMALE ............................. 00

L3. Are you now . . .

Married, .............................. 01

Living with someone as married, ........... 02

Widowed, ............................ 03

Divorced, ............................. 04

Separated, ............................ 05

Or have you never been married? .......... 06
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 35 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ........................ 01

SECOND GRADE ...................... 02

THIRD GRADE ........................ 03

FOURTH GRADE ...................... 04

FIFTH GRADE ........................ 05

SIXTH GRADE ........................ 06

SEVENTH GRADE ..................... 07

EIGHTH GRADE ....................... 08

NINTH GRADE ........................ 09

TENTH GRADE ....................... 10

ELEVENTH GRADE .................... 11

TWELFTH GRADE ..................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) . . 13

GED ................................ 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ......................... 15

SOME COLLEGE ...................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE ............................. 17

OTHER (SPECIFY) ..................... 18

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 36 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

L5. Are you Hispanic, Latino or of Spanish origin?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

REFUSED ............................ -3

L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7.-

L7a. NO QUESTIONS THIS VERSION.

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
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M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT ........................... 01

GOOD ................................ 02

FAIR ................................. 03

POOR ................................ 04

M2. Did the respondent seem to have any trouble understanding English?

YES .................................. 01

NO ................................... 00

M3. Were there any questions that the respondent complained about?

YES .................................. 01

NO ................................... 00 ! SKIP TO M4
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 38 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\EN-SHORT.Q7 39 (REV - 1/21/98--WP70) 12/16/99 12:10 PM

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\EN-LONG.Q7--WHITE QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 12:36 PM

OMB No.: 0584-0486

Expiration Date: 11/98

ELDERLY NONPARTICIPANT

LONG INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\EN-LONG.Q7 2 (REV--1/21/98--WP70) 12/16/99 12:36 PM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Elderly Nonparticipant--Long

A. HOUSEHOLD COMPOSITION

A1. Please tell me the first name or initials of each person who currently lives in your

household starting with you. By household I mean people who live with you and

share food with you.

PROBE: Include any persons who live with you more than half time.

A2. How is (NAME) related to you? ENTER CODE BELOW.

A3. How old (are you/is NAME)? PROBE: Your best estimate is fine.

Person

Number First Name or Initials Relationship Age

A1. A2. A3.

1. ______________________ SELF

|___|___|

DON’T KNOW .......... -1

2. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

3. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

4. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

5. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

6. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

7. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

8. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

9. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1

10. ______________________ |___|___|

|___|___|

DON’T KNOW .......... -1
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RELATIONSHIP CODES

01 MALE SPOUSE/PARTNER 06 GRANDMOTHER 11 OTHER MALE RELATIVE

02 FEMALE SPOUSE/PARTNER 07 SON/STEPSON OR NONRELATIVE

03 FATHER/STEPFATHER 08 DAUGHTER/STEPDAUGHTER 12 OTHER FEMALE RELATIVE

04 MOTHER/STEPMOTHER 09 BROTHER/STEPBROTHER OR NONRELATIVE

05 GRANDFATHER 10 SISTER/STEPSISTER
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A4. I’ve recorded the following names (READ NAMES FROM A1). Is there anyone

else such as babies or small children? Anyone who usually lives with you but is

now away from home, or anyone else staying here?

YES ..................... 01 ! GO BACK AND

CORRECT A1-A3

NO ...................... 00
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B. KNOWLEDGE OF THE FSP

B0. Before we talked to you about this survey, had you heard of food stamps or the

Food Stamp Program?

YES ..................... 01

NO ...................... 00 ! SKIP TO F1, PAGE 29

B1. NO QUESTION THIS VERSION.

B2. As far as you know, do any of your relatives, friends, neighbors, or co-workers

currently receive food stamp benefits?

YES ..................... 01

NO ...................... 00

DON’T KNOW ............. -1

B3.-

B8. NO QUESTIONS THIS VERSION.
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C. FSP PARTICIPATION HISTORY

C1. Have you received food stamp benefits in the past 3 years?

YES ..................... 01 ! SKIP TO C2a

NO ...................... 00

C2. Over the course of your adult life, have you ever received food stamp benefits?

YES ..................... 01 

SKIP TO D1

NO ...................... 00

C2a. Did you receive food stamp benefits for more than 3 months since February 1,

1997?

YES ..................... 01

NO ...................... 00

DON’T KNOW ............. -1

C3. When was the last time you received food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

C3a. INTERVIEWER: IS DATE MORE THAN THREE YEARS AGO?

YES ................................. 01 ! SKIP TO D1

NO .................................. 00

DON’T KNOW ......................... -1
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C4. How did you get your food stamp benefits in (DATE FROM C3)? Did you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called

Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ............... 01

EBT CARD ............... 02

C4a. What was the amount of food stamp benefits you received in (DATE FROM C3)?

$ |___|,|___|___|___|

DON’T KNOW ............. -1

C5. Did you stop receiving food stamp benefits in (DATE FROM C3) because you

were notified that you were not eligible?

YES ..................... 01 ! SKIP TO C13a

NO ...................... 00
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C6. Why did you stop participating in the food stamp program in (DATE FROM C3)? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

NOT WORTH THE EFFORT FOR

THE AMOUNT OF BENEFITS ............ 01

NO LONGER NEEDED FOOD STAMP

BENEFITS ............................ 02

EMBARRASSED USING FOOD STAMP

BENEFITS ............................ 03

THOUGHT NO LONGER ELIGIBLE ........ 04

THOUGHT SITUATION WOULD

IMPROVE ............................ 05

HARD TO GET TO FOOD STAMP OFFICE . . 06

PROCESS OF RECEIVING FOOD

STAMP BENEFITS IS TOO LONG

OR COMPLICATED .................... 07

HAD TO ANSWER TOO MANY

PERSONAL QUESTIONS ................ 08

FAMILY MEMBERS DISAPPROVED

OF MY/OUR RECEIVING FOOD

STAMP BENEFITS ..................... 09

DO NOT LIKE TO RELY ON

GOVERNMENT ASSISTANCE ............ 10

OTHER PEOPLE NEEDED THEM MORE ... 11

NOT TREATED WELL BY STAFF ......... 12

OFFICE IS VERY UNPLEASANT .......... 13

OFFICE IN AN UNSAFE

NEIGHBORHOOD ..................... 14

OTHER (SPECIFY) ..................... 15

 

 |__|__| |__|__|
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C7.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1 SKIP TO C13c

REFUSED ............................. -3

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH ..................... 01

TOO MANY ASSETS .................... 02

MISSING PAPERWORK .................. 03

CITIZENSHIP STATUS ................... 04

DID NOT SATISFY WORK

REQUIREMENTS ....................... 05

ON STRIKE FROM JOB .................. 06

OTHER (SPECIFY) ...................... 07

 

 |__|__| |__|__|

DON’T KNOW .......................... -1
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SKIP TO C13c

C13a. Why were you found ineligible? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH ..................... 01

TOO MANY ASSETS .................... 02

MISSING PAPERWORK .................. 03

CITIZENSHIP STATUS ................... 04

DID NOT SATISFY WORK

REQUIREMENTS ....................... 05

ON STRIKE FROM JOB .................. 06

OTHER (SPECIFY) ...................... 07

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

C13b. NO QUESTION THIS VERSION.

C13c. When you received food stamps in the past, did you ever do things so that

people will not find out you receive food stamp benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES .................................. 01

NO ................................... 00
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C14. Now I’m going to ask you some questions about your experiences with food

stamp benefits over the past three years.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in

stores, were you sometimes treated

disrespectfully by either employees or

customers? ........................ 01 00

b. Were you embarrassed to use food stamp

benefits? .......................... 01 00

c. Did you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Did you feel that you really needed food

stamp benefits to make it through the

month? ............................ 01 00

e. Did you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Did you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Did food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Did you experience other difficulties with food stamp benefits that you have not

already mentioned? Please do not include any difficulties you had applying, we

will ask about this later.

YES .................................. 01

NO ................................... 00 ! SKIP TO D1
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C16. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|
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D. HISTORY OF APPLICATIONS

D1. Have you applied for food stamp benefits in the past 3 years? By applied I mean

have you at least completed a new application form?

YES .................................. 01

NO ................................... 00 

SKIP TO D14

DON’T KNOW .......................... -1

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ................................. 01 ! SKIP TO D4c

NO .................................. 00

DON’T KNOW ......................... -1
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D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ....................... 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ..................... 01

AUTHORIZED REPRESENTATIVE ........ 02

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE .............. 01

AT SSI OFFICE ....................... 02

AT A SENIOR CENTER ................ 03 SKIP TO D4f

AT A HOSPITAL ...................... 04

AT A HOUSING COMPLEX ............. 05

SOMEWHERE ELSE (PLEASE SPECIFY) . . 06

 

 |__|__| |__|__|

AT HOME ........................... 07
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D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ...................... 01

VISIT BY CASEWORKER ............... 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES ................................ 01

NO ................................. 00

DON’T KNOW ........................ -1

DOESN’T WORK ..................... -4

D4g. The last time you applied, did you have a lot of help with the application?

YES ................................ 01

NO ................................. 00 

SKIP TO D5

DON’T KNOW ........................ -1
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D4h. What type of help did you receive? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D4i. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
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D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

 |__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
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D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ................................ 01

NO ................................. 00 ! SKIP TO D8

D7b. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|
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D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO D10

REFUSED ............................ -3
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D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|
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D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................. 01

NO .................................. 00 

SKIP TO D12

DON’T KNOW ......................... -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH ..................... 01

TOO MANY ASSETS .................... 02

MISSING PAPERWORK .................. 03

CITIZENSHIP STATUS ................... 04

DID NOT SATISFY WORK

REQUIREMENTS ....................... 05

ON STRIKE FROM JOB .................. 06

OTHER (SPECIFY) ...................... 07

 

 |__|__| |__|__|

DON’T KNOW .......................... -1
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D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them but did not use any

of them.

YES .................................. 01

NO ................................... 00 

SKIP TO E1

DON’T KNOW .......................... -1

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD

STAMP BENEFITS ........................ 01

NOT TREATED WELL IN FOOD STORES ...... 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ................... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS ...... 04

NOT TREATED WELL BY OFFICE/PROGRAM . . 04

TOO HARD TO PICK UP COUPONS/STAMPS . . 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN ............................. 07

BENEFIT AMOUNT WAS TOO SMALL ........ 08

DID NOT NEED FOOD STAMPS ............. 09

OTHER (SPECIFY) ........................ 10

 

 |__|__| |__|__|
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GO TO E1

D14. Have you contacted the food stamp office to ask about food stamp benefits in

the past 3 years?

YES .................................. 01

NO ................................... 00 ! SKIP TO E1

D15. When was the last time you contacted the food stamp office to ask about food

stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D16. Which of the following reasons led you to ask about food stamp benefits in

(DATE FROM D15)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from

family, friends, government programs, or other sources (such

as food banks)? ................................. 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility

for food stamp benefits? ........................... 01 00

j. Some other reason? (SPECIFY) ....................

 |__|__| |__|__|

01 00
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D16a.-

D16b. NO QUESTIONS THIS VERSION.

D16c. Why didn’t you complete an application form at that time? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ........................ 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK ............... 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ........................ 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE .................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|

D17.-

D21. NO QUESTIONS THIS VERSION.
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E. NONPARTICIPATION

Now I would like to talk to you about the reasons you currently do not use food stamps.

E1. E2. E4.

Is this an important reason

you don’t use food stamp

benefits?

YES NO KNOW YES NO KNOW REASON

DON’T DON’T IMPORTANT

MOST

a. Do you know where to go or who to

contact to apply for food stamp SKIP 

benefits? ...................... 01 !TO E1b 00 -1 01 00 -1 01

b. Do you think you are currently eligible SKIP 

for food stamp benefits? .......... 01 !TO E1c 00 -1 01 00 -1 02

c. Do you think it would be hard to get SKIP SKIP 

to the food stamp office? .......... 01 00 ! TO E1d -1 !TO E1d 01 00 -1 03

d. Do you think the application process SKIP SKIP 

is too long and complicated? ....... 01 00 ! TO E1e -1 !TO E1e 01 00 -1 04

e. Do you think you would have to

answer questions that are too

personal when applying for food SKIP SKIP 

stamp benefits? ................. 01 00 ! TO E1f -1 ! TO E1f 01 00 -1 05

f. Do you think you would feel

embarrassed applying for SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1g -1 !TO E1g 01 00 -1 06

g. Do you think you would be eligible for

only a small amount of food stamp SKIP SKIP 

benefits? ...................... 01 00 ! TO E1h -1 !TO E1h 01 00 -1 07

h. Can you get by on your own without SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1i -1 ! TO E1i 01 00 -1 08

i. Do you feel that others need food SKIP SKIP 

stamp benefits more than you do? . . 01 00 ! TO E1j -1 ! TO E1j 01 00 -1 09

j. Would you feel embarrassed using SKIP SKIP 

food stamp benefits? ............. 01 00 ! TO E1k -1 !TO E1k 01 00 -1 10

k. Would you dislike relying on SKIP SKIP 

government assistance? .......... 01 00 ! TO E1l -1 ! TO E1l 01 00 -1 11

l. Would other family members or

friends discourage you from using SKIP SKIP 

food stamp benefits? ............. 01 00 !TO E1m -1 !TO E1m 01 00 -1 12

m. Do you think that staff at the food

stamp office would treat you SKIP SKIP 

disrespectfully? ................. 01 00 ! TO E1n -1 !TO E1n 01 00 -1 13

n. Do you think that the food stamp

office would be very unpleasant or SKIP SKIP 

you would not be safe? ........... 01 00 ! TO E1o -1 !TO E1o 01 00 -1 14

o. Do you think your need for food SKIP SKIP 

stamp benefits is only temporary? ... 01 00 ! TO E1p -1 !TO E1p 01 00 -1 15
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p. Are there other important reasons

why you do not use food stamp

benefits that we have not just SKIP SKIP

mentioned? ....................

RECORD VERBATIM BELOW:

 |__|__| |__|__|

01 00 ! TO E3 -1 ! TO E3 01 00 -1 16
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E3. INTERVIEWER: HOW MANY “YESES” ARE CIRCLED IN QUESTION E2?

NONE ................................ 00 

SKIP TO E5

ONE ................................. 01

MORE THAN ONE ...................... 02

E4. Of all the reasons you gave (READ IMPORTANT REASONS FROM E2 IF

NECESSARY), what is the most important reason you do not currently use food

stamp benefits? RECORD IN COLUMN MARKED E4.

E5. INTERVIEWER: WAS THE RESPONSE TO E1b “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E7

E6. You said you think you are currently eligible for food stamp benefits. How much

in food stamp benefits do you think you would qualify for each month? Your best

estimate is fine.

CIRCLE ONE RESPONSE

$10 OR LESS ......................... 01

BETWEEN $11 AND $25 ................ 02

BETWEEN $26 AND $50 ................ 03

BETWEEN $51 AND $100 ............... 04

BETWEEN $101 AND $150 .............. 05

BETWEEN $151 AND $200 .............. 06

BETWEEN $201 AND $300 .............. 07

MORE THAN $300 ..................... 08

DON’T KNOW ......................... -1

GO TO E9
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E7. You said you think you are not currently eligible for food stamp benefits. Why do

you think that you are not eligible to receive food stamp benefits? RECORD

VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DO NOT SATISFY WORK 

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__| 

DON’T KNOW ......................... -1

E8. Do you think you are currently ineligible because you were told by someone at

the food stamp office that you are ineligible?

YES ................................. 01

NO .................................. 00 ! SKIP TO E8b

E8a. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN THE LAST MONTH .............. 01

WITHIN THE LAST 3 MONTHS ........... 02

WITHIN THE LAST YEAR ............... 03

MORE THAN ONE YEAR AGO ........... 04

DON’T KNOW ......................... -1
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E8b. Were you told by someone at another program that you are ineligible for food

stamp benefits?

YES ................................. 01 ! SKIP TO E9

NO .................................. 00

DON’T KNOW ......................... -1

E8c. Do you think you are ineligible because you know someone like you who is

ineligible?

YES ................................. 01

NO .................................. 00

E9. INTERVIEWER: WAS THE RESPONSE TO E1c “YES”?

YES ................................ 01

NO ................................. 00 ! SKIP TO E11

E10. You said you think it would be hard to get to the food stamp office.

Is this . . .

YES NO

a. Because it is difficult or expensive to get

transportation? ................................... 01 00

b. Because of difficulties you have getting around? ......... 01 00

c. Because of difficulties you would have taking time

off work? ....................................... 01 00

d. Because you would lose pay going to the

food stamp office? ................................ 01 00

e. Because you would have to pay for someone

to take care of someone in your home? ................ 01 00

f. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ..............................

 |__|__| |__|__|

01 00
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E11. INTERVIEWER: WAS THE RESPONSE TO E1d “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12. You think the application process would be too long and complicated. Is

this . . .

YES NO

a. Because you think you would have to wait a long time

to be served? .................................... 01 00

PROBE: A long time from your point of view.

b. Because you think the application form is too long and

complicated? .................................... 01 00

c. Because you think it would be difficult to get all the necessary

paperwork? ..................................... 01 00

d. Because of some other reason I haven’t mentioned?

(PLEASE SPECIFY) ..............................

 |__|__| |__|__|

01 00

E12a. INTERVIEWER: WAS THE RESPONSE TO PART “a” OF E12 “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E13

E12b. You said you would have to wait a long time to be served. How long do you think

you would have to wait? Would it be . . .

15 minutes or less? ...................... 01

16 to 30 minutes? ....................... 02

31 minutes to one hour? .................. 03

Or, more than one hour? .................. 04

DON’T KNOW .......................... -1
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E13. INTERVIEWER: WAS THE RESPONSE TO E1e “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E15

E14. You said you would have to answer questions that were too personal. What type

of questions do you feel are too personal?

CIRCLE ALL THAT APPLY

WHO LIVES IN HOUSEHOLD ............. 01

CITIZENSHIP .......................... 02

DISABILITIES .......................... 03

RESOURCES/ASSETS .................. 04

INCOME .............................. 05

MEDICAL EXPENSES ................... 06

DEPENDENT-CARE EXPENSES ........... 07

SHELTER EXPENSES ................... 08

CHILD SUPPORT PAYMENTS ............ 09

OTHER (SPECIFY) ...................... 10

 

 |__|__| |__|__|

E15. INTERVIEWER: WAS THE RESPONSE TO E1g “YES”?

YES .................................. 01

NO ................................... 00 ! SKIP TO E17

E16. You said you think you are eligible for only a small amount of food stamp

benefits.
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E16a. Were you told by someone at a food stamp office that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01

NO ................................ 00 

 SKIP TO E16c

DON’T KNOW ....................... -1

E16b. Were you told this within the last month, within the last three months, within the

last year, or more than one year ago?

WITHIN LAST MONTH ................ 01

WITHIN LAST 3 MONTHS ............. 02

WITHIN THE LAST YEAR ............. 03

MORE THAN ONE YEAR AGO ......... 04

DON’T KNOW ....................... -1

SKIP TO E17

E16c. Were you told by someone at another program that you were eligible for only a

small amount of food stamp benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

E16d. Do you think that you would receive only a small amount of benefits because you

know someone like you who receives only a small amount of benefits?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1
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E17. INTERVIEWER: WAS THE RESPONSE TO E1n “YES”?

YES ............................... 01

NO ................................ 00 ! SKIP TO E19

E18. You thought the food stamp office would be very unpleasant or you would not be

safe? Is this . . .

YES NO

a. Because the inside of the building would be

unpleasant? ................................ 01 00

b. Because you wouldn’t like waiting with the other

applicants? ................................. 01 00

c. Because the office would be in an unsafe

neighborhood? .............................. 01 00

d. Because of something else? (SPECIFY) ......... 01 00

 |__|__| |__|__|

E19. Do you agree with the statement made by some people that “its OK to receive

food stamp benefits if you pay taxes”?

YES .............................. 01

NO ............................... 00
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F. RECEIPT OF FOOD ASSISTANCE

F1. During the past 12 months, did (you/anyone in the household) ever receive free

or reduced-cost meals for the elderly either at a facility or delivered to your

home?

PROBE: By facility we mean places such as a senior center or community

center or some other special place with a meal program.

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

F1a. INTERVIEWER: ARE THERE ANY CHILDREN UNDER 18 IN THE

HOUSEHOLD?

YES .................................. 01

NO CHILDREN ......................... 00 ! SKIP TO F5

F2. During the past 12 months, did any children in the household ever receive free or

reduced-cost meals at a day-care or Head Start program?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

CHILD/CHILDREN DO NOT ATTEND

DAY CARE PROGRAM .................. -4
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F3. Not counting meals at Head Start or daycare programs, during the past 12

months, did any children in the household ever receive free or reduced-cost

lunches at school?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

CHILD/CHILDREN DO NOT

ATTEND SCHOOL ...................... -4! SKIP TO F5

F4. During the past 12 months, did any children in the household ever receive free or

reduced-cost breakfasts at school?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F5. INTERVIEWER: CHECK QUESTION A1: IS ANYONE IN THIS

HOUSEHOLD EITHER UNDER AGE 6 OR A WOMAN

UNDER 45 YEARS OF AGE?

YES .................................. 01

NO ................................... 00 ! SKIP TO F7

F6. During the past 12 months, did (you/anyone in the household) ever get food

through the WIC program?

PROBE: By WIC we mean the U.S. Department of Agriculture’s Special

Supplemental Nutrition Program for Women, Infants, and Children,

which provides food packages and nutrition education to women,

infants, and young children.

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1
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(SPECIFY PROGRAM):

 |__|__| |__|__|

F7. During the past 12 months, did (you/anyone in the household) ever get food, or

vouchers to buy food, from any other kind of program?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F8. In the last 12 months, did you (or other adults in your household) ever get food or

borrow money for food from friends or relatives?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F9. In the last 12 months, did you (or other adults in your household) ever get

emergency food from a church, a food pantry, or food bank?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F10. In the last 12 months, did you (or other adults in your household) ever eat any

meals at a soup kitchen?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1
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Where?

 |__|__| |__|__|

F10a. In the last 12 months, did you (or other adults in the household) ever receive free

or reduced-price meals at work?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

F11. Some people are able to get food from their own garden or farm, or from hunting

or fishing. During the last 12 months, did you (anyone in the household) ever get

food from . . .

YES NO

a. Your own vegetable garden? ........................... 01 00 

b. Meat, poultry, or eggs from animals you raise? ............. 01 00 

c. Meat or fish from hunting or fishing? ..................... 01 00 

F11a. In the last 12 months, did you (or other adults in your household) ever get free

food from any source we haven’t already mentioned?

PROBE: Please include any free meals or groceries that you receive from any

person or source that we haven’t already mentioned

YES .................................. 01

NO ................................... 00
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INTERVIEWER: IF RESPONSE CODE IS FOLLOWED BY AN ASTERISK (*),

CIRCLE THE QUESTION NUMBER.

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G2. “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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G3. “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or

never true for (you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
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G4. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G8

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G6. “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we)

couldn’t afford that.” Was that often, sometimes, or never true for (you/your

household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
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G7. “(My/Our child was/The children were) not eating enough because (I/we) just

couldn’t afford enough food.” Was that often, sometimes, or never true for

(you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G8. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

33 AND 34? IS THE RESPONSE TO G1, G2, G3, G5, OR G6 “OFTEN TRUE”

(01) OR “SOMETIMES TRUE” (02)?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G10

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1
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G10. In the last 12 months, did you ever eat less than you felt you should because there

wasn’t enough money to buy food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G11. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t

afford enough food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G12. In the last 12 months, did you lose weight because you didn’t have enough

money for food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01 *

NO .................................. 00 

 SKIP TO G14

DON’T KNOW ......................... -1
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G13a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G14. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G15. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

35 AND 36? IS THE RESPONSE TO G7 “OFTEN TRUE” (01) OR

“SOMETIMES TRUE” (02) OR IS THERE A “YES” RESPONSE TO G11, G12 OR

G13?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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G17. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals

because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 SKIP TO G18

DON’T KNOW ......................... -1

G17a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G18. In the last 12 months, (was your child/were the children) ever hungry but you just

couldn’t afford more food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G19. In the last 12 months, did (your child/any of the children) ever not eat for a whole

day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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H. EMPLOYMENT HISTORY

H1. Including yourself, which people in your household work at a job for pay? RECORD NAMES AT H1.

NONE .................................. 00 ! SKIP TO I1

HOUSEHOLD NAMES RECORDED BELOW ... 01

H2. How many hours per week (does NAME/do you)usually work? RECORD BELOW OPPOSITE

PERSONS NAME. PROBE: Your best estimate would be fine.

INTERVIEWER: IF RESPONDENT UNABLE TO TELL YOU USUAL HOURS WORKED PER

WEEK, ASK “HOW MANY HOURS DID YOU WORK LAST WEEK OR DURING

THE MOST RECENT WEEK YOU WORKED IF YOU DID NOT WORK LAST

WEEK?”

H3. How much (does NAME/do you) earn on this job, before taxes and any other deductions are taken out?

RECORD BELOW FOR EACH PERSON.

INTERVIEWER: IF RESPONDENT RECEIVES TIPS AS PART OF EARNINGS, ASK

RESPONDENT TO REPORT WHAT HE OR SHE EARNED LAST WEEK (OR

MOST RECENT WEEK WORKED IF NOT LAST WEEK) INCLUDING TIPS, AND

RECORD AS “SALARY PER WEEK.”

PROBE: What is (NAME’S/YOUR) gross pay?

H1 H2 H3

Name Hours Hourly OR Salary Per Salary Basis

Per Week Wage

1 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

2 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

3 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

4 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
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5 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

H4.-H11. NO QUESTIONS THIS VERSION.
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I. HEALTH

I1. Would you say that your current health condition is excellent, good, fair or poor?

EXCELLENT ........................... 01

GOOD ................................ 02

FAIR ................................. 03

POOR ................................ 04

I2. Next, I will read a list of activities with which some people have difficulty because

of a health or physical reason. Please tell me if you have no difficulty, some

difficulty, a great deal of difficulty, or are unable to do these activities without the

use of aids or another person?

NO SOME DEAL OF UNABLE KNOW/

DIFFICULTY DIFFICULTY DIFFICULTY TO DO DON’T DO

A GREAT DON’T

a. Eating, bathing, dressing, getting

around your home or other

personal care needs ........ 01 02 03 04 -1

b. Managing your money (such as

keeping track of your expenses

or paying bills, balancing a check

book, or filling out tax forms) . . 01 02 03 04 -1

c. Getting out of your home to shop

or visit a doctor’s office ...... 01 02 03 04 -1
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J. SOCIAL SUPPORTS

J1. How long have you lived in your neighborhood?

IF LESS THAN ONE YEAR, ENTER “00” FOR YEARS AND RECORD

NUMBER OF MONTHS.

|___|___| / |___|___|

YEARS MONTHS

OR

SINCE |___|___| 19 |___|___|

MONTH YEAR

J2. In a typical week during the past year, how often did you get together in person

with friends, neighbors, or relatives? By get together I mean going out together

or visiting in each other’s homes? Did you get together . . .

Every day, ............................. 07

Five or six times a week, .................. 05

Three or four times a week, ............... 03

Once or twice a week, or .................. 01

Less than once per week? ................ 00

J3. How close do you live to your nearest relative who does not live with you? Do

you live less than 30 minutes away, 30 minutes to 2 hours away, or more than 2

hours away?

CIRCLE ONE

LESS THAN 30 MINUTES AWAY .......... 01

30 MINUTES TO 2 HOURS AWAY ......... 02

MORE THAN 2 HOURS AWAY ............ 03

NO LIVING CHILDREN OR RELATIVES ..... -4
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K. INCOME AND EXPENSES

K1. Which of the following best describes where you live now . . .

A place you own, ........................ 01

A place you rent, ........................ 02 ! SKIP TO K5

A place where you live rent free, ............ 03 

SKIP TO K6

Or someplace else? (SPECIFY) ............ 04

 

 |__|__| |__|__|

K2. What is your monthly mortgage payment?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K3. (Do you/Does your household) make a separate home insurance payment?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

K4. (Do you/Does your household) pay a separate property tax bill?

YES .................................. 01

NO ................................... 00 SKIP TO K6

DON’T KNOW .......................... .-1
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K5. What is your monthly rent payment? Please tell me only the amount that you and

members of your household pay out-of-pocket.

PROBE: Do not include any rent subsidies that your household receives from

any program to pay part of the rent costs.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K5a. (Do you/Does your household) pay separate heating or air-conditioning costs?

YES .................................. 01

NO ................................... 00

K6. INTERVIEWER: CHECK GRID A1 THROUGH A3. HOW MANY PEOPLE

ARE IN HOUSEHOLD?

ONE ................................. 01 ! SKIP TO K7b

MORE THAN ONE ...................... 02

K6a. Last month, did (you/your household) pay out-of-pocket for the care of children or

other dependents so that someone in your household could go to work, school,

or a training program?

YES .................................. 01

NO ................................... 00 ! SKIP TO K7b

DON’T KNOW .......................... -1

K6b. How much did (you/your household) pay out-of-pocket last month?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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K7. NO QUESTION THIS VERSION.

K7a. NO QUESTION THIS VERSION.

K7b. Is anyone in your household disabled? Please count as disabled persons who

receive SSI benefits because of a disability, social security disability checks,

disability retirement pensions, railroad retirement disability payments, or veteran

disability benefits.

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

K7c. NO QUESTION THIS VERSION.

K8. Last month, did (you/your household) pay health insurance premiums or

payments to belong to an HMO?

YES .................................. 01

NO ................................... 00 

SKIP TO K9

DON’T KNOW .......................... -1

K8a. How much did (you/your household) pay last month. Please tell me only the

amount that you and members of your household pay out-of-pocket.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K8b. NO QUESTION THIS VERSION.

K9. Now think about the people in your household who are disabled or age 60 or

older. Last month, how much were their out-of-pocket medical expenses? 

Include doctor and hospital bills, prescription drugs, lab tests or X-rays, and any

other medical expenses you paid out-of-pocket. Please exclude anything for

which you will be reimbursed.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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INTERVIEWER: CHECK GRID A1 THROUGH A3: IF RESPONDENT LIVES ALONE, DON’T ASK

K12, K13, OR K14. THAT IS, ALWAYS SKIP TO NEXT QUESTION IN K10 AFTER

COMPLETING K11 FOR EACH INCOME SOURCE.

K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

1. CO: Colorado Works; [STATE WELFARE NAME]/ DON’T

MA: Transitional Aid to Temporary Assistance for Needy NAME AMOUNT KNOW

Families with Dependent Families (TANF)?

Children; __________________ $ |___|,|___|___|___| -1

MN: MFIP Minnesota’s $ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

Family Investment __________________ $ |___|,|___|___|___| -1 

Program; DON’T NO ......... 00 6 GO TO K10.2

NC: Work First Benefits KNOW. . .-1 ! GO TO K12 __________________

PA/TX: Temporary $ |___|,|___|___|___| -1 

Assistance for Needy __________________

Families (TANF)?

YES ...... 01

NO ....... 00 6 ASK K12

$ |___|,|___|___|___| -1 

2. General Assistance, General Assistance, general relief, DON’T

general relief, or welfare? or welfare? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.3 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________

__________________ 

 

$ |___|,|___|___|___| -1

$ |___|,|___|___|___| -1 

3. Social Security checks Social Security checks from the DON’T

from the government? government? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.4 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

4. Other retirement benefits Other retirement benefits (that are DON’T

(that are not Social not Social Security) such as a NAME AMOUNT KNOW

Security) such as a government or private pension or

government or private annuity? __________________ $ |___|,|___|___|___| -1

pension or annuity? 

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.5 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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5. SSI or Supplemental SSI or Supplemental Security DON’T

Security Income from the Income from the federal, state, or NAME AMOUNT KNOW

federal, state, or local local government?

government? __________________ $ |___|,|___|___|___| -1

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.6 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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6. Veteran's benefits? Veteran's benefits? DON’T

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01

DON’T NO ......... 00 6 GO TO K10.7 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

NAME AMOUNT KNOW

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

7. Unemployment Insurance Unemployment Insurance or DON’T

or workman's workman's compensation NAME AMOUNT KNOW

compensation benefits? benefits?

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.8

KNOW. . .-1 ! GO TO K12 __________________

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________

$ |___|,|___|___|___| -1 

$ |___|,|___|___|___| -1 

8. Any child support Any child support payments or DON’T

payments or alimony? alimony? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12

DON’T 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K10.9 __________________ $ |___|,|___|___|___| -1 

YES ......... 01 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

9. Payments from roomers or Payments from roomers or DON’T

boarders? boarders? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.10 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 

10. Financial support from Financial support from friends or DON’T

friends or family? family? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.11 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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11. Any other income such as Any other income such as income DON’T

income from business or from business or prizes? NAME AMOUNT KNOW

prizes?

YES ..... 01 ! (SPECIFY)

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 __________________ $ |___|,|___|___|___| -1 

DON’T __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K15

YES ......... 01 ! SPECIFY

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
H:\PROJECT\8305\012\Ques\EN-LONG.Q7 55 (REV--1/21/98--WP70) 12/16/99 12:36 PM

K15. Do you (or does anybody in your household) own a car, truck, van, or

motorcycle? Please include any cars, trucks, vans, or motorcycles 

that you’re making payments on.

YES .................................. 01

NO ................................... 00 ! SKIP TO K18

K16. What (is/are) the year(s), make(s), and model(s) of the car(s), truck(s), van(s), or

motorcycle(s)?

PROBE: Please include any vehicle owned by a household member.

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

DON’T KNOW .......................... -1 ! ASK K17

SKIP TO K18

K17. INTERVIEWER: IF YEAR, MAKE OR MODEL ARE UNKNOWN, ASK:

What is the approximate value of each vehicle owned by

household members?

Vehicle 1: $ ________________________

Vehicle 2: $ ________________________

Vehicle 3: $ ________________________
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K18. (Including yourself, is anyone in your household/Are you) legally required to pay

child support?

YES .................................. 01

NO ................................... 00 ! SKIP TO L2

K19. In total, how much child support (was paid by all members of your household/did

you pay) last month?

$ |___|___|, |___|___|___| ! SKIP TO L2

DON’T KNOW .......................... -1

REFUSED ............................. -3

K20. Would you tell me which of the following ranges best describes the total amount

of child support paid last month?

More than $250 ......................... 01 ! SKIP TO K22

Exactly $250 ........................... 02 ! SKIP TO L2

Less than $250 ......................... 03

DON’T KNOW/REFUSED ................. -3 ! SKIP TO L2

K21. Was it . . .

$50 or less, ............................ 01

Between $51 and $100, .................. 02

Between $101 and $150, ................. 03 SKIP TO L2

Between $151 and $200, ................. 04

Or, between $201 and $250? .............. 05

DON’T KNOW/REFUSED ................. -3
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K22. Was it . . .

Between $250 and $300, ................. 01

Between $301 and $350, ................. 02

Between $351 and $400, ................. 03

Between $401 and $450, ................. 04

Or, over $450? ......................... 05

DON’T KNOW/REFUSED ................. -3
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L. DEMOGRAPHIC INFORMATION

L1. NO QUESTION THIS VERSION.

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ................................ 01

FEMALE .............................. 00

L3. Are you now . . .

Married, ............................... 01

Living with someone as married, ............ 02

Widowed, ............................. 03

Divorced, .............................. 04

Separated, ............................. 05

Or have you never been married? ........... 06
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L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ......................... 01

SECOND GRADE ....................... 02

THIRD GRADE ......................... 03

FOURTH GRADE ....................... 04

FIFTH GRADE ......................... 05

SIXTH GRADE ......................... 06

SEVENTH GRADE ...................... 07

EIGHTH GRADE ........................ 08

NINTH GRADE ......................... 09

TENTH GRADE ........................ 10

ELEVENTH GRADE ..................... 11

TWELFTH GRADE ...................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) ... 13

GED ................................. 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE .......................... 15

SOME COLLEGE ....................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE .............................. 17

OTHER (SPECIFY) ...................... 18

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

REFUSED ............................. -3
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L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7. Is everyone in your household a U.S. citizen?

YES .................................. 01 ! SKIP TO L8

NO ................................... 00

L7a. Is anyone in your household a U.S. citizen?

YES .................................. 01

NO ................................... 00

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
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M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT ........................... 01

GOOD ................................ 02

FAIR ................................. 03

POOR ................................ 04

M2. Did the respondent seem to have any trouble understanding English?

YES .................................. 01

NO ................................... 00

M3. Were there any questions that the respondent complained about?

YES .................................. 01

NO ................................... 00 ! SKIP TO M4
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M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
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M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7--ORANGE QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 12:52 PM

OMB No.: 0584-0486

Expiration Date: 11/98

ELDERLY PARTICIPANT

SHORT INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
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OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Elderly Participant--Short

A. HOUSEHOLD COMPOSITION

A1s. How many people in your household are 60 years of age or older? By household

I mean yourself and the people who currently live with you and share food with

you.

PROBE: Include any persons who live with you more than half time.

|___|___|

A2s. Including yourself, how many people in your household are under 18 years of

age?

|___|___|

A3s. Including yourself, how many people in your household currently work at a job for

pay?

|___|___|

NONE ............................... 00 ! SKIP TO C4

A4s. Do you work at a job for pay?

YES ................................. 01

NO .................................. 00
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B. NO SECTION B

C. FSP PARTICIPATION HISTORY

C1.-

C3a. NO QUESTIONS THIS VERSION.

C4. How do you currently get your food stamp benefits each month? Do you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT card is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ........................... 01

EBT CARD ........................... 02

C4a.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO C13c

REFUSED ............................ -3
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C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

C13a.-

C13b. NO QUESTIONS THIS VERSION.

C13c. Do you ever do things so that people will not find out you receive food stamp

benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ................................. 01

NO .................................. 00
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C14. Now I’m going to ask you some questions about your experiences with food

stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in

stores, are you sometimes treated

disrespectfully by either employees or

customers? ........................ 01 00

b. Are you embarrassed to use food stamp

benefits? .......................... 01 00

c. Do you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Do you feel that you really needed food

stamp benefits to make it through the

month? ............................ 01 00

e. Do you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Do you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Do food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Have you experienced other difficulties with food stamp benefits that you have

not already mentioned? Please do not include any difficulties you had applying,

we will ask about this later.

YES ................................. 01

NO .................................. 00 ! SKIP TO D2
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C16. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|
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D. HISTORY OF APPLICATIONS

D1. NO QUESTION THIS VERSION.

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 8 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ................................ 01 ! SKIP TO D4c

NO ................................. 00

DON’T KNOW ........................ -1

D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ....................... 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 9 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ................ 01

AT SSI OFFICE ......................... 02

AT A SENIOR CENTER .................. 03 SKIP TO D7

AT A HOSPITAL ........................ 04

AT A HOUSING COMPLEX ............... 05

SOMEWHERE ELSE (PLEASE SPECIFY) ... 06

 

 |__|__| |__|__|

AT HOME ............................. 07

D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ........................ 01

VISIT BY CASEWORKER ................ 02

D4f.-

D4i. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 10 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. NO QUESTION THIS VERSION.

c. The number of people in your household changed? ...... 01 00

d. NO QUESTION THIS VERSION.

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. NO QUESTION THIS VERSION.

h. NO QUESTION THIS VERSION.

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

|__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 11 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the food

stamp office? ................................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ................................. 01

NO .................................. 00 ! SKIP TO D8

D7b. Please describe those difficulties. RECORD VERBATIM

|___|___| |___|___|
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 12 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1 SKIP TO D10

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 13 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 14 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................. 01

NO .................................. 00 

SKIP TO D12

DON’T KNOW ......................... -1

D11. Thinking about the last time you applied for food stamp benefits and were found

ineligible to receive food stamp benefits, why were you found ineligible? 

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 15 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them 

but did not use any of them.

YES ................................. 01

NO .................................. 00 

SKIP TO D17

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 16 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP

BENEFITS ............................ 01

NOT TREATED WELL IN FOOD STORES . . 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ............... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS . . 04

NOT TREATED WELL BY OFFICE/

PROGRAM ........................... 05

TOO HARD TO PICK UP COUPONS/

STAMPS ............................. 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN .......................... 07

BENEFIT AMOUNT WAS TOO SMALL ..... 08

DID NOT NEED FOOD STAMPS .......... 09

OTHER (SPECIFY) ..................... 10

 

 |__|__| |__|__|

D14.-

D16. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 17 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

(PLEASE SPECIFY):

|__|__| |__|__|

D17. Now I would like to talk to you about some things that may have helped you

decide to use food stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. Did you receive a lot of help with the

application? ........................ 01 00

b. Did other family members or friends 

encourage you to get food stamp 

benefits? .......................... 01 00

c. Do you feel it’s OK to receive food stamp

benefits because you pay taxes? ........ 01 00

d. Do you feel you couldn’t get by on your own

without food stamp benefits? ........... 01 00

e. Are you uncomfortable getting food 

from family, friends, charities, or other 

programs? ......................... 01 00

D18. Are there other circumstances that we haven’t mentioned that helped you decide

to use food stamp benefits?

YES ................................. 01

NO .................................. 00

D19. INTERVIEWER: CHECK QUESTION D17a. DID THEY RECEIVE A LOT OF

HELP WITH THE APPLICATION?

YES ............................... 01

NO ................................ 00 ! SKIP TO G1
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 18 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

D20. You said you received a lot of help with the application, what type of help did you

receive? RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D21. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 19 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

E. NO SECTION E

F. NO SECTION F

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G2.-

G4. NO QUESTIONS THIS VERSION.

G4s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G9
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 20 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01

Sometimes true ........................ 02

Never true ............................ 03

DON’T KNOW ......................... -1

G6.-

G8. NO QUESTIONS THIS VERSION.

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G13

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G10.-

G12. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 21 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 

 SKIP TO G14s

DON’T KNOW ......................... -1

G14. NO QUESTION THIS VERSION.

G14s. INTERVIEWER: CHECK QUESTION A2s. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO L1

G15. NO QUESTION THIS VERSION.

G16. The next questions are about children living in the household who are under 18

years old.

In the last 12 months, since (CURRENT MONTH) of last year, did you ever cut the

size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G17.-

G19. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 22 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

H. NO SECTION H

I. NO SECTION I

J. NO SECTION J 

K. NO SECTION K

L. DEMOGRAPHIC INFORMATION

L1. Now, I have just a few final questions.

Can you tell me your age?

|___|___| / |___|___| / 19 |___|___|

MONTH DAY YEAR

OR |___|___| YEARS OLD

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................... 01

FEMALE ............................. 00

L3. Are you now . . .

Married, .............................. 01

Living with someone as married, ........... 02

Widowed, ............................ 03

Divorced, ............................. 04

Separated, ............................ 05

Or have you never been married? .......... 06
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 23 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ........................ 01

SECOND GRADE ...................... 02

THIRD GRADE ........................ 03

FOURTH GRADE ...................... 04

FIFTH GRADE ........................ 05

SIXTH GRADE ........................ 06

SEVENTH GRADE ..................... 07

EIGHTH GRADE ....................... 08

NINTH GRADE ........................ 09

TENTH GRADE ....................... 10

ELEVENTH GRADE .................... 11

TWELFTH GRADE ..................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) . . 13

GED ................................ 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ......................... 15

SOME COLLEGE ...................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE ............................. 17

OTHER (SPECIFY) ..................... 18

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

REFUSED ............................ -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

REFUSED ............................ -3
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 24 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7.-

L7a. NO QUESTIONS THIS VERSION.

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 25 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT ........................... 01

GOOD ................................ 02

FAIR ................................. 03

POOR ................................ 04

M2. Did the respondent seem to have any trouble understanding English?

YES .................................. 01

NO ................................... 00

M3. Were there any questions that the respondent complained about?

YES .................................. 01

NO ................................... 00 ! SKIP TO M4
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 26 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES .................................. 01

NO ................................... 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
H:\PROJECT\8305\012\Ques\EP-SHORT.Q7 27 (REV - 1/21/98--WP70) 12/16/99 12:52 PM

M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE
H:\PROJECT\8305\012\Ques\EP-LONG.Q7--YELLOW QC: CODER: _______________ DATE: _______________

(REV - 1/21/98--WP70) 12/16/99 1:07 PM

OMB No.: 0584-0486

Expiration Date: 11/98

ELDERLY PARTICIPANT

LONG INTERVIEW

Interviewer ID: |__|__|__|__|__| Date Completed: |__|__|/|__|__|/19|__|__|

Month Day Year

MPR ID: |___|___|___|___|___|___|___|___|

Name of Original Respondent: 

Name of Respondent: 

Phone Number: |__|__|__| - |__|__|__| - |__|__|__|__|

 Area Code

Time Zone: 9 Eastern 9 Central 9 Mountain

9 Elderly in Household

Callbacks/Appointments

Intv ID Date Time Status Callback Date Callback Time

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

________ ___/___ _____A/P _____ ___/___ ______A/P

NOTES:

STATUS CODES:

INTERIM FINAL

20 CALLBACK/APPOINTMENT 01 COMPLETE

21 CALLBACK/NO APPOINTMENT 02 REFUSAL

22 NO ANSWER/BUSY 03 INCOMPLETE/BREAKOFF

23 ANSWERING MACHINE 04 UNLOCATABLE

24 WRONG#/CHANGED # 05 UNAVAILABLE DURING FIELD PERIOD

25 INITIAL REFUSAL(SCREENER COMPLETE) 06 CHRONIC NO ANSWER/BUSY

27 INCOMPLETE/BREAKOFF 07 ANSWERING MACHINE

28 RESPONDENT OUT OF TOWN 08 BARRIER (LANG/PHY/COGN)

29 RESPONDENT WILL CALL MPR 09 OTHER

30 NEEDS NEW LETTER

31 OTHER
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 2 (REV--1/21/98--WP70) 12/16/99 1:07 PM

OMB No.: 0584-0486

INTERVIEWER ID #: |___|___|___|___|___| DATE: |___|___| / |___|___| / 19 |___|___|

MPR ID #: |___|___|___|___|___|___|___|___| MONTH DAY YEAR

TIME BEGAN: |__|__|:|__|__| AM....01 PM....02

WP & PE STUDY

Main Questionnaire: Elderly Participant--Long

A. HOUSEHOLD COMPOSITION

A1. Please tell me the first name or initials of each person who currently lives in your

household starting with you. By household I mean people who live with you and

share food with you.

PROBE: Include any persons who live with you more than half time.

A2. How is (NAME) related to you? ENTER CODE BELOW.

A3. How old (are you/is NAME)? PROBE: Your best estimate is fine.

Person

Number First Name or Initials Relationship Age

A1. A2. A3.

1. ______________________ SELF

|___|___|

DON’T KNOW ......... -1

2. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

3. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

4. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

5. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

6. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

7. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

8. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

9. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1

10. ______________________ |___|___|

|___|___|

DON’T KNOW ......... -1
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 3 (REV--1/21/98--WP70) 12/16/99 1:07 PM

RELATIONSHIP CODES

01 MALE SPOUSE/PARTNER 06 GRANDMOTHER 11 OTHER MALE RELATIVE

02 FEMALE SPOUSE/PARTNER 07 SON/STEPSON OR NONRELATIVE

03 FATHER/STEPFATHER 08 DAUGHTER/STEPDAUGHTER 12 OTHER FEMALE RELATIVE

04 MOTHER/STEPMOTHER 09 BROTHER/STEPBROTHER OR NONRELATIVE

05 GRANDFATHER 10 SISTER/STEPSISTER
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 4 (REV--1/21/98--WP70) 12/16/99 1:07 PM

A4. I’ve recorded the following names (READ NAMES FROM A1). Is there anyone

else such as babies or small children? Anyone who usually lives with you but is

now away from home, or anyone else staying here?

YES ..................... 01 ! GO BACK AND

CORRECT A1-A3

NO ...................... 00
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 5 (REV--1/21/98--WP70) 12/16/99 1:07 PM

B. KNOWLEDGE OF THE FSP

B1. NO QUESTION THIS VERSION.

B2. As far as you know, do any of your relatives, friends, neighbors, or co-workers

currently receive food stamp benefits?

YES ..................... 01

NO ...................... 00

DON’T KNOW ............. -1

B3.-

B8. NO QUESTIONS THIS VERSION.
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 6 (REV--1/21/98--WP70) 12/16/99 1:07 PM

C. FSP PARTICIPATION HISTORY

C1.-

C3. NO QUESTIONS THIS VERSION.

C4. How do you currently get your food stamp benefits each month? Do you get

coupons or credit to an EBT card?

PROBE: In Colorado, the EBT car is called Colorado Quest.

In Massachusetts, the EBT card is called an EBT card.

In Texas, the EBT card is called the Lone Star card.

No EBT card in Minnesota, North Carolina or Pennsylvania.

COUPONS ......................... 01

EBT CARD ......................... 02

C4a.-

C11. NO QUESTIONS THIS VERSION.

C12. In the past 3 years, did you ever stop receiving food stamp benefits because you

were notified that you were not eligible?

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1 SKIP TO C13c

REFUSED .......................... -3
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 7 (REV--1/21/98--WP70) 12/16/99 1:07 PM

C13. Thinking about the last time you were found ineligible to receive food stamp

benefits, what were the reasons? RECORD VERBATIM AND CIRCLE ALL

THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................. 01

TOO MANY ASSETS ................. 02

MISSING PAPERWORK ............... 03

CITIZENSHIP STATUS ................ 04

DID NOT SATISFY WORK

REQUIREMENTS .................... 05

ON STRIKE FROM JOB ............... 06

OTHER (SPECIFY) ................... 07

 

 |__|__| |__|__|

DON’T KNOW ....................... -1

C13a.-

C13b. NO QUESTIONS THIS VERSION.

C13c. Do you ever do things so that people will not find out you receive food stamp

benefits?

PROBE: For example, some people try to use their food stamp benefits in

stores where they are unlikely to meet anyone they know.

YES ............................... 01

NO ................................ 00
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 8 (REV--1/21/98--WP70) 12/16/99 1:07 PM

C14. Now I’m going to ask you some questions about your experiences with food

stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. When using food stamp benefits in 

stores, are you sometimes treated

disrespectfully by either employees or

customers? ........................ 01 00

b. Are you embarrassed to use food stamp

benefits? .......................... 01 00

c. Do you have any difficulties obtaining your

monthly food stamp benefits? .......... 01 00

d. Do you feel that you really need food stamp

benefits to make it through the month? ... 01 00

e. Do you have any difficulties doing all the

paperwork needed to keep getting food

stamp benefits? ..................... 01 00

f. Do you have any difficulties arranging

meetings with your caseworker at

convenient times? ................... 01 00

g. Do food stamp office staff ever treat you

disrespectfully? ..................... 01 00

C15. Have you experienced other difficulties with food stamp benefits that you have

not already mentioned? Please do not include any difficulties you had applying,

we will ask about this later.

YES ............................... 01

NO ................................ 00 ! SKIP TO D2

C16. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|
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D. HISTORY OF APPLICATIONS

D1. NO QUESTION THIS VERSION.

D2. When was the last time you applied for food stamp benefits?

|___|___| 19 |___|___|

MONTH YEAR

D3. All these next questions refer to the last time you applied for food stamp benefits

in (MONTH YEAR FROM D2).

When you applied for food stamp benefits in (MONTH/YEAR FROM D2), did you

also apply for any other kinds of public assistance such as Supplemental

Security Income (or SSI), AFDC, [FILL STATE WELFARE NAME], Medicaid, or

general assistance?

Colorado Colorado Works

Massachusetts Transitional Aid to Families with Dependent Children

Minnesota MFIP Minnesota’s Family Investment Program

North Carolina Work First Benefits

Pennsylvania TANF

Texas TANF

YES ............................... 01

NO ................................ 00

DON’T KNOW ....................... -1

D4a. The last time you applied, did you or someone else mail or take the application

form to a food stamp office?

YES ............................... 01 ! SKIP TO D4c

NO ................................ 00

DON’T KNOW ....................... -1
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D4b. Did you or someone else mail or take the application form to an SSI office, a

senior center, a hospital, a housing complex, or somewhere else?

CIRCLE ONE

AN SSI OFFICE, ........................ 01

A SENIOR CENTER, .................... 02

A HOSPITAL, .......................... 03

A HOUSING COMPLEX, OR .............. 04

SOMEWHERE ELSE? (PLEASE SPECIFY) . . 05

 

 |__|__| |__|__|

D4c. The last time you applied, did you apply yourself or did an authorized

representative apply for you?

APPLIED MYSELF ...................... 01

AUTHORIZED REPRESENTATIVE ......... 02

D4d. Where did (you/your authorized representative) have the interview with your

caseworker?

AT FOOD STAMP OFFICE ............... 01

AT SSI OFFICE ........................ 02

AT A SENIOR CENTER ................. 03 SKIP TO D4f

AT A HOSPITAL ....................... 04

AT A HOUSING COMPLEX .............. 05

SOMEWHERE ELSE (PLEASE SPECIFY) . . 06

 

 |__|__| |__|__|

AT HOME ............................ 07
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D4e. Did you have your interview by telephone or did a caseworker come to your

home?

BY TELEPHONE ....................... 01

VISIT BY CASEWORKER ............... 02

D4f. The last time you applied, did you take time off from work to apply for food stamp

benefits?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

DOESN’T WORK ...................... -4

D4g. NO QUESTION THIS VERSION.
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D5. Which of the following reasons led you to apply for food stamp benefits in

(MONTH, YEAR FROM D2)?

YES NO

a. Your household income fell? ........................ 01 00

b. You or someone in your household lost a job? .......... 01 00

c. The number of people in your household changed? ...... 01 00

d. You or someone in your household became ill or

disabled? ....................................... 01 00

e. It was getting harder and harder to make ends meet? .... 01 00

f. You couldn’t get as much food as you needed from family,

friends, government programs, or other sources (such as food

banks)? ........................................ 01 00

g. You couldn’t get the kinds of food you needed from family,

friends, government programs, or other sources? ....... 01 00

h. You didn’t want to get food from family, friends, government

programs, or other sources? ........................ 01 00

i. You learned about the program or your eligibility for food

stamp benefits? ................................. 01 00

j. Some other reason? (SPECIFY) ....................

______________________________________________

______________________________________________

 |__|__| |__|__|

01 00

D5a.-

D6. NO QUESTIONS THIS VERSION.
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D7. Now I am going to ask you some questions about your experiences applying for

food stamp benefits over the past 3 years.

CIRCLE “YES” OR “NO”

YES NO N/A

a. Was it difficult or expensive for you to get transportation to

the food stamp office? ............................ 01 00 --

b. Did you have to go to the food stamp office even though

your health or disability made it difficult? .............. 01 00 --

c. Was it difficult for you to take time off from work to apply

for food stamp benefits? ........................... 01 00 -4

d. Did you lose wages when you went to apply for food stamp

benefits? ...................................... 01 00 -4

e. Did you have to arrange for care of someone in your home

so that you could go to the food stamp office? .......... 01 00 --

f. Did you have to wait a long time to be served at the

food stamp office? ............................... 01 00 --

PROBE: A long time from your point of view.

g. Were staff at the food stamp office disrespectful? ....... 01 00 --

h. Do you think the application form was too long and

complicated? ................................... 01 00 --

i. Did your caseworker ask you questions that were too

personal? ...................................... 01 00 --

j. Was it difficult for you to get all the necessary

paperwork? .................................... 01 00 --

k. Did you feel embarrassed having to apply for food stamps? 01 00 --

D7a. Did you experience other difficulties applying for food stamp benefits that you

have not already mentioned?

YES ................................ 01

NO ................................. 00 ! SKIP TO D8
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D7b. Please describe those difficulties. RECORD VERBATIM

 |__|__| |__|__|

D8. In the past 3 years, did you ever begin the food stamp application process and

not complete it?

YES ................................ 01

NO ................................. 00

DON’T KNOW ........................ -1 SKIP TO D10

REFUSED ........................... -3
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D9. Why didn’t you complete the application process at that time?

RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

DIDN’T THINK ELIGIBLE ................ 01

BENEFIT TOO LOW .................... 02

APPLICATION TOO TIME-CONSUMING .... 03

APPLICATION FORM TOO

COMPLICATED ....................... 04

APPLICATION TOO PERSONAL .......... 05

TOO MUCH PAPERWORK .............. 06

DIDN’T KNOW HOW TO COMPLETE

THE PROCESS ....................... 07

NOT TREATED WELL BY STAFF ......... 08

STIGMA/EMBARRASSMENT/PRIDE ....... 09

HEALTH/MOBILITY PROBLEMS .......... 10

LANGUAGE/LITERACY PROBLEMS ....... 11

MY SITUATION CHANGED .............. 12

TRANSPORTATION PROBLEM ........... 13

HARD TO GET TIME OFF WORK ......... 14

LOSE WAGES WHEN I GO TO

FOOD STAMP OFFICE ................. 15

OTHER (SPECIFY) ..................... 16

 

 |__|__| |__|__|
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D10. In the past 3 years, have you applied for food stamp benefits and been found

ineligible?

YES ................................. 01

NO .................................. 00 

SKIP TO D12

DON’T KNOW ......................... -1

D11. Thinking about the last time you applied for food stamps and were found

ineligible, why were you found ineligible? RECORD VERBATIM AND CIRCLE

ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

INCOME TOO HIGH .................... 01

TOO MANY ASSETS ................... 02

MISSING PAPERWORK ................. 03

CITIZENSHIP STATUS .................. 04

DID NOT SATISFY WORK

REQUIREMENTS ...................... 05

ON STRIKE FROM JOB ................. 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

DON’T KNOW ......................... -1
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D12. In the past 3 years, have you ever been found eligible for food stamp benefits but

not used them?

PROBE: By that I mean, you were found to be eligible for food stamp benefits

and you did not pick them up or you received them but did not use any

of them.

YES ................................. 01

NO .................................. 00 

SKIP TO D17

DON’T KNOW ......................... -1
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D13. The last time that happened, why didn’t you use them? RECORD VERBATIM

AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

EMBARRASSED TO USE FOOD STAMP

BENEFITS ............................ 01

NOT TREATED WELL IN FOOD STORES . . 02

NO STORES NEARBY THAT ACCEPT

FOOD STAMP BENEFITS ............... 03

DID NOT LIKE TO SHOP AT STORES

THAT ACCEPT FOOD STAMP BENEFITS . . 04

NOT TREATED WELL BY OFFICE/

PROGRAM ........................... 05

TOO HARD TO PICK UP COUPONS/

STAMPS ............................. 06

STAMPS OR EBT CARD WERE LOST

OR STOLEN .......................... 07

BENEFIT AMOUNT WAS TOO SMALL ..... 08

DID NOT NEED FOOD STAMPS .......... 09

OTHER (SPECIFY) ..................... 10

 

 |__|__| |__|__|

D14.-

D16c. NO QUESTIONS THIS VERSION.
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(PLEASE SPECIFY):

 |__|__| |__|__|

D17. Now I would like to talk to you about some things that may have helped you

decide to use food stamp benefits.

CIRCLE “YES” OR “NO”

FOR EACH STATEMENT

YES NO

a. Did you receive a lot of help with the

application? ........................ 01 00

b. Did other family members or friends

encourage you to get food stamp

benefits? .......................... 01 00

c. Do you feel it’s OK to receive food stamp

benefits because you’ve paid taxes? ..... 01 00

d. Do you feel you couldn’t get by on your own

without food stamp benefits? ........... 01 00

e. Are you uncomfortable getting food 

from family, friends, charities, or other 

programs? ......................... 01 00

D18. Are there other circumstances that I haven’t mentioned that helped you decide to

use food stamp benefits?

YES ................................. 01

NO .................................. 00

D19. INTERVIEWER: CHECK QUESTION D17a. DID THEY RECEIVE A LOT OF

HELP WITH THE APPLICATION?

YES ................................. 01

NO .................................. 00 ! SKIP TO F1
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D20. You said you received a lot of help with the application, what type of help did you

receive? RECORD VERBATIM AND CIRCLE ALL THAT APPLY.

|___|___| |___|___|

CIRCLE ALL THAT APPLY

TRANSPORTATION TO THE OFFICE ...... 01

HAVING SOMEONE BE WITH ME

AT THE FOOD STAMP OFFICE ........... 02

HAVING SOMEONE ELSE GO TO

OFFICE INSTEAD OF ME ............... 03

TRANSLATION ........................ 04

HELP FILLING OUT APPLICATION ........ 05

HELP OBTAINING NECESSARY

DOCUMENTATION ..................... 06

OTHER (SPECIFY) ..................... 07

 

 |__|__| |__|__|

D21. Who provided this help?

CIRCLE ALL THAT APPLY

CASEWORKER ....................... 01

RELATIVE, FRIEND, OR NEIGHBOR ...... 02

CLERGYMAN ......................... 03

COMMUNITY WORKER (OUTREACH

WORKER OR LEGAL AID

REPRESENTATIVE) .................... 04

VOLUNTEER AT FOOD STAMP OFFICE ... 05

OTHER (SPECIFY) ..................... 06

 

 |__|__| |__|__|
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 21 (REV--1/21/98--WP70) 12/16/99 1:07 PM

E. NO SECTION E

F. RECEIPT OF FOOD ASSISTANCE

F1. During the past 12 months, did (you/anyone in the household) ever receive free

or reduced-cost meals for the elderly either at a facility or delivered to your

home?

PROBE: By facility we mean places such as a senior center or community

center or some other special place with a meal program.

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F1a. INTERVIEWER: ARE THERE ANY CHILDREN UNDER 18 IN THE

HOUSEHOLD?

YES ................................. 01

NO CHILDREN ........................ 00 ! SKIP TO F5

F2. During the past 12 months, did any children in the household ever receive free or

reduced-cost meals at a day-care or Head Start program?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

CHILD/CHILDREN DO NOT

ATTEND DAY CARE PROGRAM .......... -4
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F3. Not counting meals at Head Start or daycare programs, during the past 12

months, did any children in the household ever receive free or reduced-cost

lunches at school?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

CHILD/CHILDREN DO NOT

ATTEND SCHOOL ..................... 04 ! SKIP TO F5

F4. During the past 12 months, did any children in the household ever receive free or

reduced-cost breakfasts at school?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F5. INTERVIEWER: CHECK QUESTION A3. IS ANYONE IN THIS

HOUSEHOLD EITHER UNDER AGE 6 OR A WOMAN

UNDER 45 YEARS OF AGE?

YES ................................. 01

NO .................................. 00 ! SKIP TO F7

F6. During the past 12 months, did (you/anyone in the household) ever get food

through the WIC program?

PROBE: By WIC we mean the U.S. Department of Agriculture’s Special

Supplemental Nutrition Program for Women, Infants, and Children,

which provides food packages and nutrition education to women,

infants, and young children.

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 23 (REV--1/21/98--WP70) 12/16/99 1:07 PM

(SPECIFY PROGRAM):

 

 |__|__| |__|__|

F7. During the past 12 months, did (you/anyone in the household) ever get food, or

vouchers to buy food, from any other kind of program?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F8. In the last 12 months, did you (or other adults in your household) ever get food or

borrow money for food from friends or relatives?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F9. In the last 12 months, did you (or other adults in your household) ever get

emergency food from a church, a food pantry, or food bank?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F10. In the last 12 months, did you (or other adults in your household) ever eat any

meals at a soup kitchen?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 24 (REV--1/21/98--WP70) 12/16/99 1:07 PM

Where?

 |__|__| |__|__|

F10a. In the last 12 months, did you (or other adults in the household) ever receive free

or reduced-price meals at work?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

F11. Some people are able to get food from their own garden or farm, or from hunting

or fishing. During the last 12 months, did you (anyone in the household) ever get

food from . . .

YES NO

a. Your own vegetable garden? ............................ 01 00 

b. Meat, poultry, or eggs from animals you raise? .............. 01 00 

c. Meat or fish from hunting or fishing? ...................... 01 00 

F11a. In the last 12 months, did you (or other adults in your household) ever get free

food from any source we haven’t already mentioned?

PROBE: Please include any free meals or groceries that you receive from any

person or source that we haven’t already mentioned.

YES ................................. 01

NO .................................. 00

F12. NO QUESTION THIS VERSION.
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INTERVIEWER: IF RESPONSE CODE IS FOLLOWED BY AN ASTERISK (*),

CIRCLE THE QUESTION NUMBER.

G. FOOD SECURITY

G1. 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 12

months, that is, since last (MONTH 12 MONTHS AGO).

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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G2. “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 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G3. “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or

never true for (you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
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G4. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO G8

G5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/the

children) because (I was/we were) running out of money to buy food.” Was that

often, sometimes, or never true for (you/your household) in the last 12 months?

PROBE: By low-cost food we mean rice, beans, macaroni products, bread, or

potatoes, or foods like that.

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G6. “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we)

couldn’t afford that.” Was that often, sometimes, or never true for (you/your

household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1
H:\PROJECT\8305\012\Ques\EP-LONG.Q7 27 (REV--1/21/98--WP70) 12/16/99 1:07 PM

G7. “(My/Our child was/The children were) not eating enough because (I/we) just

couldn’t afford enough food.” Was that often, sometimes, or never true for

(you/your household) in the last 12 months?

Often true ............................ 01 *

Sometimes true ........................ 02 *

Never true ............................ 03

DON’T KNOW ......................... -1

G8. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

22 AND 23? IS THE RESPONSE TO G1, G2, G3, G5, OR G6 “OFTEN TRUE”

(01) OR “SOMETIMES TRUE” (02)?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G9. In the last 12 months, since last (MONTH 12 MONTHS AGO), 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?

YES ................................. 01

NO .................................. 00 

 SKIP TO G10

DON’T KNOW ......................... -1

G9a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1
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G10. In the last 12 months, did you ever eat less than you felt you should because there

wasn’t enough money to buy food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G11. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t

afford enough food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G12. In the last 12 months, did you lose weight because you didn’t have enough

money for food?

YES ................................. 01 *

NO .................................. 00

DON’T KNOW ......................... -1

G13. In the last 12 months, did (you/you or other adults in your household) ever not eat

for a whole day because there wasn’t enough money for food?

YES ................................. 01 *

NO .................................. 00 

 SKIP TO G14

DON’T KNOW ......................... -1
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G13a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G14. INTERVIEWER: CHECK QUESTION A3. ARE THERE ANY CHILDREN

UNDER 18 IN THE HOUSEHOLD?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G15. INTERVIEWER: ARE ANY QUESTION NUMBERS CIRCLED ON PAGES

24 AND 25? IS THE RESPONSE TO G7 “OFTEN TRUE” (01) OR

“SOMETIMES TRUE” (02) OR IS THERE A “YES” RESPONSE TO G11, G12 OR

G13?

YES ................................. 01

NO .................................. 00 ! SKIP TO H1

G16. The next questions are about children living in the household who are under 18

years old.

in the last 12 months, since (CURRENT MONTH) of last year, did you ever cut

the size of (your child’s/any of the children’s) meals because there wasn’t enough

money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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G17. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals

because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00 SKIP TO G18

DON’T KNOW ......................... -1

G17a. How often did this happen--almost every month, some months but not every

month, or in only 1 or 2 months?

Almost every month ..................... 01

Some months but not every month ......... 02

Only 1 or 2 months ..................... 03

DON’T KNOW ......................... -1

G18. In the last 12 months, (was your child/were the children) ever hungry but you just

couldn’t afford more food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

G19. In the last 12 months, did (your child/any of the children) ever not eat for a whole

day because there wasn’t enough money for food?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1
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H. EMPLOYMENT HISTORY

H1. Including yourself, which people in your household work at a job for pay? RECORD NAMES AT H1.

NONE .................................. 00 ! SKIP TO I1

HOUSEHOLD NAMES RECORDED BELOW ... 01

H2. How many hours per week (does NAME/do you) usually work for pay? RECORD BELOW OPPOSITE

PERSONS NAME. PROBE: Your best estimate would be fine.

INTERVIEWER: IF RESPONDENT UNABLE TO TELL YOU USUAL HOURS WORKED PER

WEEK, ASK “HOW MANY HOURS DID YOU WORK LAST WEEK OR DURING

THE MOST RECENT WEEK YOU WORKED IF YOU DID NOT WORK LAST

WEEK?”

H3. How much (does NAME/do you) earn on this job, before taxes and any other deductions are taken out?

RECORD BELOW FOR EACH PERSON.

INTERVIEWER: IF RESPONDENT RECEIVES TIPS AS PART OF EARNINGS, ASK

RESPONDENT TO REPORT WHAT HE OR SHE EARNED LAST WEEK (OR

MOST RECENT WEEK WORKED IF NOT LAST WEEK) INCLUDING TIPS, AND

RECORD AS “SALARY PER WEEK.”

PROBE: What is (NAME’S/YOUR) gross pay?

H1 H2 H3

Name Hours Hourly OR Salary Per Salary Basis

Per Week Wage

1 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

2 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

3 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

4 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06
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5 ________________ |___|___| $ |___|___|.|___|___|/HR. OR $ |___|___|,|___|___|___| Per Day ........ 01

_

CODER:

Person # from A1:

|___|___|

DON’T KNOW ... -1 DON’T KNOW ..... -1 DON’T KNOW ..... -1

Week ...... 02

2 Weeks .... 03

2X Month ... 04

Month ...... 05

Year ....... 06

H4.-H11. NO QUESTIONS THIS VERSION.
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I. HEALTH

I1. Would you say that your current health condition is excellent, good, fair or poor?

EXCELLENT .......................... 01

GOOD ............................... 02

FAIR ................................ 03

POOR ............................... 04

I2. Next, I will read a list of activities with which some people have difficulty because

of a health or physical reason. Please tell me if you have no difficulty, some

difficulty, a great deal of difficulty, or are unable to do these activities without the

use of aids or another person?

NO SOME DEAL OF UNABLE KNOW/

DIFFICULTY DIFFICULTY DIFFICULTY TO DO DON’T DO

A GREAT DON’T

a. Eating, bathing, dressing,

getting around your home or

other personal care needs ... 01 02 03 04 -1

b. Managing your money (such as

keeping track of your expenses

or paying bills, balancing a

check book, or filling out tax

forms) ................... 01 02 03 04 -1

c. Getting out of your home to

shop or visit a doctor’s office . . 01 02 03 04 -1
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J. SOCIAL SUPPORTS

J1. How long have you lived in your neighborhood?

IF LESS THAN ONE YEAR, ENTER “00” FOR YEARS AND RECORD

NUMBER OF MONTHS.

|___|___| / |___|___|

YEARS MONTHS

 OR

SINCE |___|___| 19 |___|___|

MONTH YEAR

J2. In a typical week during the past year, how often did you get together in person

with friends, neighbors, or relatives? By get together I mean going out together

or visiting in each other’s homes? Did you get together . . .

Every day, ............................ 07

Five or six times a week, ................. 05

Three or four times a week, .............. 03

Once or twice a week, or ................. 01

Less than that? ........................ 00

J3. How close do you live to your nearest relative who does not live with you? Do

you live less than 30 minutes away, 30 minutes to 2 hours away, or more than 2

hours away?

CIRCLE ONE

LESS THAN 30 MINUTES AWAY .......... 01

30 MINUTES TO 2 HOURS AWAY ......... 02

MORE THAN 2 HOURS AWAY ............ 03

NO LIVING CHILDREN OR RELATIVES ..... -4
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K. INCOME AND EXPENSES

K1. Which of the following best describes where you live now . . .

A place you own, ........................ 01

A place you rent, ........................ 02 ! SKIP TO K5

A place where you live rent free, ............ 03 

SKIP TO K6

Or someplace else? (SPECIFY) ............ 04

 

 |__|__| |__|__|

K2. What is your monthly mortgage payment?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K3. (Do you/Does your household) make a separate home insurance payment?

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

K4. (Do you/Does your household) pay a separate property tax bill?

YES .................................. 01

NO ................................... 00 SKIP TO K6

DON’T KNOW .......................... -1
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K5. What is your monthly rent payment? Please tell me only the amount that you and

members of your household pay out-of-pocket.

PROBE: Do not include any rent subsidies that your household receives from

any program to pay part of the rent costs.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K5a. (Do you/Does your household) pay separate heating or air-conditioning costs?

YES .................................. 01

NO ................................... 00

K6. INTERVIEWER: CHECK GRID A1 THROUGH A3. HOW MANY PEOPLE

ARE IN HOUSEHOLD?

ONE ................................. 01 ! SKIP TO K7b

MORE THAN ONE ...................... 02

K6a. Last month, did (you/your household) pay out-of-pocket for the care of children or

other dependents so that someone in your household could go to work, school,

or a training program?

YES .................................. 01

NO ................................... 00 ! SKIP TO K7b

DON’T KNOW .......................... -1

K6b. How much did (you/your household) pay out-of-pocket last month?

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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K7.-

K7a. NO QUESTIONS THIS VERSION.

K7b. Is anyone in your household disabled? Please count as disabled persons who

receive SSI benefits because of a disability, social security disability checks,

disability retirement pensions, railroad retirement disability payments, or veteran

disability benefits.

YES .................................. 01

NO ................................... 00

DON’T KNOW .......................... -1

K8. Last month, did (you/your household) pay health insurance premiums or

payments to belong to an HMO?

YES .................................. 01

NO ................................... 00 

SKIP TO K9

DON’T KNOW .......................... -1

K8a. How much did (you/your household) pay last month. Please tell me only the

amount that you and members of your household pay out-of-pocket.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1

K8b. NO QUESTION THIS VERSION.

K9. Now think about the people in your household who are disabled or age 60 or

older. Last month, how much were their out-of-pocket medical expenses? 

Include doctor and hospital bills, prescription drugs, lab tests or X-rays, and any

other medical expenses you paid out-of-pocket. Please exclude anything for

which you will be reimbursed.

$ |___|, |___|___|___|

DON’T KNOW .......................... -1
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INTERVIEWER: CHECK GRID A1 THROUGH A3: IF RESPONDENT LIVES ALONE, DON’T ASK

K12, K13, OR K14. THAT IS, ALWAYS SKIP TO NEXT QUESTION IN K10 AFTER

COMPLETING K11 FOR EACH INCOME SOURCE.

K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

1. CO: Colorado Works; [STATE WELFARE NAME]/ DON’T

MA: Transitional Aid to Temporary Assistance for Needy NAME AMOUNT KNOW

Families with Dependent Families (TANF)?

Children; __________________ $ |___|,|___|___|___| -1

MN: MFIP Minnesota’s $ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

Family Investment __________________ $ |___|,|___|___|___| -1 

Program; DON’T NO ......... 00 6 GO TO K10.2

NC: Work First Benefits KNOW. . .-1 ! GO TO K12 __________________

PA/TX: Temporary $ |___|,|___|___|___| -1 

Assistance for Needy __________________

Families (TANF)?

YES ...... 01

NO ....... 00 6 ASK K12

$ |___|,|___|___|___| -1 

2. General Assistance, General Assistance, general relief, DON’T

general relief, or welfare? or welfare? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.3 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________

__________________ 

 

$ |___|,|___|___|___| -1

$ |___|,|___|___|___| -1 

3. Social Security checks Social Security checks from the DON’T

from the government? government? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.4 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

4. Other retirement benefits Other retirement benefits (that are DON’T

(that are not Social not Social Security) such as a NAME AMOUNT KNOW

Security) such as a government or private pension or

government or private annuity? __________________ $ |___|,|___|___|___| -1

pension or annuity? 

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GO TO K10.5 __________________ $ |___|,|___|___|___| -1

KNOW. . .-1 ! GO TO K12 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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5. SSI or Supplemental SSI or Supplemental Security DON’T

Security Income from the Income from the federal, state, or NAME AMOUNT KNOW

federal, state, or local local government?

government? __________________ $ |___|,|___|___|___| -1

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.6 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

6. Veteran's benefits? Veteran's benefits? DON’T

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01

DON’T NO ......... 00 6 GO TO K10.7 

KNOW. . .-1 ! GO TO K12 __________________ $ |___|,|___|___|___| -1

NAME AMOUNT KNOW

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 

 

7. Unemployment Insurance Unemployment Insurance or DON’T

or workman's workman's compensation NAME AMOUNT KNOW

compensation benefits? benefits?

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 

DON’T NO ......... 00 6 GO TO K10.8

KNOW. . .-1 ! GO TO K12 __________________

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________

$ |___|,|___|___|___| -1 

$ |___|,|___|___|___| -1 

8. Any child support Any child support payments or DON’T

payments or alimony? alimony? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12

DON’T 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K10.9 __________________ $ |___|,|___|___|___| -1 

YES ......... 01 __________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

9. Payments from roomers or Payments from roomers or DON’T

boarders? boarders? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.10 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 
K10 K11 K12 K13 K14

During (LAST MONTH) How much did you Did anyone else in your Who else How much did (NAME)

did you receive any . . . receive from household receive any received receive from

(SOURCE) last (SOURCE) last month? (SOURCE) last (SOURCE) last month? 

month? month? ENTER AMOUNT

RECEIVED FOR EACH

NAME.

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10. Financial support from Financial support from friends or DON’T

friends or family? family? NAME AMOUNT KNOW

YES ..... 01

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 YES ......... 01 __________________ $ |___|,|___|___|___| -1

DON’T NO ......... 00 6 GOTO K10.11 __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12

__________________ $ |___|,|___|___|___| -1 

__________________ $ |___|,|___|___|___| -1 

 

11. Any other income such as Any other income such as income DON’T

income from business or from business or prizes? NAME AMOUNT KNOW

prizes?

YES ..... 01 ! (SPECIFY)

NO ...... 00 6 ASK K12

$ |__|,|__|__|__| 6 ASK K12 __________________ $ |___|,|___|___|___| -1 

DON’T __________________ $ |___|,|___|___|___| -1 

KNOW. . .-1 ! GO TO K12 NO ......... 00 6 GO TO K15

YES ......... 01 ! SPECIFY

__________________ $ |___|,|___|___|___| -1

__________________ $ |___|,|___|___|___| -1 

 
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K15. Do you (or does anybody in your household) own a car, truck, van, or

motorcycle? Please include any cars, trucks, vans, or motorcycles 

that you’re making payments on.

YES ................................. 01

NO .................................. 00 ! SKIP TO K18

K16. What (is/are) the year(s), make(s), and model(s) of the car(s), truck(s), van(s), or

motorcycle(s)?

PROBE: Please include any

vehicle owned by a

household member.

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

19 |___|___| Make: Model: 

DON’T KNOW ......................... -1 ! ASK K17

SKIP TO K18

K17. INTERVIEWER: IF YEAR, MAKE OR MODEL ARE UNKNOWN, ASK: What

is the approximate value of each vehicle owned by household

members?

Vehicle 1: $ ________________________

Vehicle 2: $ ________________________

Vehicle 3: $ ________________________
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K18. (Including yourself, is anyone in your household/Are you) legally required to pay

child support?

YES ................................. 01

NO .................................. 00 ! SKIP TO L2

K19. In total, how much child support (was paid by all members of your household/did

you pay) last month?

$ |___|___|,|___|___|___| ! SKIP TO L2

DON’T KNOW ......................... -1

REFUSED ............................ -3

K20. Would you tell me which of the following ranges best describes the total amount

of child support paid last month?

More than $250 ........................ 01 ! SKIP TO K22

Exactly $250 .......................... 02 ! SKIP TO L2

Less than $250 ........................ 03

DON’T KNOW/REFUSED ................ -3 ! SKIP TO L2

K21. Was it . . .

$50 or less, ........................... 01

Between $51 and $100, ................. 02

Between $101 and $150, ................ 03 SKIP TO L2

Between $151 and $200, ................ 04

Or, between $201 and $250? ............. 05

DON’T KNOW/REFUSED ................ -3
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K22. Was it . . .

Between $250 and $300, ................ 01

Between $301 and $350, ................ 02

Between $351 and $400, ................ 03

Between $401 and $450, ................ 04

Or, over $450? ........................ 05

DON’T KNOW/REFUSED ................ -3
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L. DEMOGRAPHIC INFORMATION

L1. NO QUESTION THIS VERSION.

L2. CODE WITHOUT ASKING: (ASK ONLY IF NOT OBVIOUS) Are you male or

female?

MALE ............................... 01

FEMALE ............................. 00

L3. Are you now . . .

Married, .............................. 01

Living with someone as married, ........... 02

Widowed, ............................ 03

Divorced, ............................. 04

Separated, ............................ 05

Or have you never been married? .......... 06
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L4. What is the highest grade or level of school that you have completed?

FIRST GRADE ........................ 01

SECOND GRADE ...................... 02

THIRD GRADE ........................ 03

FOURTH GRADE ...................... 04

FIFTH GRADE ........................ 05

SIXTH GRADE ........................ 06

SEVENTH GRADE ..................... 07

EIGHTH GRADE ....................... 08

NINTH GRADE ........................ 09

TENTH GRADE ....................... 10

ELEVENTH GRADE .................... 11

TWELFTH GRADE ..................... 12

GRADUATED HIGH SCHOOL (DIPLOMA) . . 13

GED ................................ 14

VOCATIONAL TRAINING PROGRAM

CERTIFICATE ......................... 15

SOME COLLEGE ...................... 16

TWO- OR FOUR-YEAR COLLEGE

DEGREE ............................. 17

OTHER (SPECIFY) ..................... 18

 

 |__|__| |__|__|

DON’T KNOW ......................... -1

REFUSED ............................ -3

L5. Are you Hispanic, Latino or of Spanish origin?

YES ................................. 01

NO .................................. 00

DON’T KNOW ......................... -1

REFUSED ............................ -3
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L6. What is your racial background? Choose one or more of the following

races . . .

INTERVIEWER: ACCEPT AND RECORD MULTIPLE RESPONSES

WITHOUT PROBING.

White, ................................ 01

Black or African American, ................ 02

American Indian or Alaska Native, .......... 03

Asian, ................................ 04

Native Hawaiian or Other Pacific Islander? .... 05

OTHER (SPECIFY) ...................... 06

 

 |__|__| |__|__|

DON’T KNOW .......................... -1

REFUSED ............................. -3

L7. Is everyone in your household a U.S. citizen?

YES .................................. 01 ! SKIP TO L8

NO ................................... 00

L7a. Is anyone in your household a U.S. citizen?

YES .................................. 01

NO ................................... 00

L8. These are all my questions. Thank you very much for your time.

TIME ENDED: |__|__|:|__|__| AM....01 PM....02
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M. INTERVIEWER OBSERVATIONS

(To be filled out after interview is completed.)

M1. In general, was the respondent’s understanding of the questions?

CIRCLE ONE

EXCELLENT .......................... 01

GOOD ............................... 02

FAIR ................................ 03

POOR ............................... 04

M2. Did the respondent seem to have any trouble understanding English?

YES ................................. 01

NO .................................. 00

M3. Were there any questions that the respondent complained about?

YES ................................. 01

NO .................................. 00 ! SKIP TO M4
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M3a. Please list the questions and describe the problems.

Question Problem

M4. Were there any questions which the respondent didn’t understand?

YES ................................. 01

NO .................................. 00 ! SKIP TO M5

M4a. Please list the questions and describe the problems.

Question Problem
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M5. Please describe any difficulties the respondent had which are not described

above.

9 NONE