FEEDING AMERICA CLIENT SURVEY
INFORMED CONSENT

 
Feeding America Riverside | San Bernardino is inviting you to answer survey questions about you, your household, and your experiences. Answers to these questions will help us better understand the types of people we serve and can help us to improve our services. The survey takes about 10 minutes. Your participation is completely voluntary. If you agree to participate, you can always change your mind and stop the interview at any time. You don’t have to answer any questions you don’t want to. Whether or not you choose to take the survey, it won’t change the services you receive from Feeding America Riverside | San Bernardino now or in the future.

As a thank you for taking the survey, we will provide you with a $5 Grocery Gift Card once you finish the survey.

Your name will never be connected to the answers you provide. All of the information we report will be at the group level, never about one individual. We do not ask for your name or other personal information, such as telephone number, that can identify you in the survey results.

HOUSEHOLD CHARACTERISTICS

If you entered "0" above, please specify your answer below.
If you entered "0" above, please specify your answer below.
Q1B1.Of the other people who live in your household, please tell us how the people who live in your household are related to you. Please check all that apply. Are they…
If you entered "0" above, please specify your answer below.
Q1A3. How do you describe your gender identity?
Q1A4a. Are you of Hispanic, Latino, or Spanish origin?
Q1A4b. What is your race? Please select all that apply.

HOUSEHOLD INCOME / EMPLOYMENT

Q1C1a. Which category represents the total combined income of all members of your family who are 15 years of age or older during the last month . Please include money from things such as jobs, net income from business, pensions, social security payments, and any other money income received. Was it…
Q1C1b. Which category represents the total combined income of all members of your family who are 15 years of age or older during the past 12 months . Please include money from things such as jobs, net income from business, pensions, social security payments, and any other money income received. Was it…
Q1C1b. Which category represents the total combined income of all members of your family who are 15 years of age or older during the past 12 months . Please include money from things such as jobs, net income from business, pensions, social security payments, and any other money income received. Was it…
Q1C2a. Did you or anyone in your household get money in the last month from any of the following sources? You can choose more than one.

TRANSPORTATION

Q1F4a. What is the primary means of transportation for you and other members of your household? You can choose more than one option.

FOOD SECURITY

Q3A1a. The following are statements that people have made about their food situation. For these statements, please say whether the statement was often true, sometimes true, or never true for you and your household in the last 12 months —that is, since last October.

“The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.”
“(I/we) couldn’t afford to eat balanced meals.”
Q3A2. In the last 12 months, since last October, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?
Q3A3.If yes, how often did this happen?
Q3A4.In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?
Q3A5.In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?

HEALTH

Q4A1.Would you say that in general, your health is excellent, very good, good, fair, or poor?

CALFRESH

We’d like to ask you some questions about your household’s participation in the federal nutrition program called CalFresh or food stamps.

Q5A1.Does anyone from the household currently receive CalFresh or food stamps?
Q5A2.How many weeks do your CalFresh benefits usually last?

CLOSEOUT

Q7A1.Before finishing the survey, do you have any notes to add or any referrals to document?

As a thank you for taking the survey, we will provide you with a $5 Grocery Gift Card.

Your name will never be connected to the answers you provided. All of the information we report will be at the group level, never about one individual. The information request below is 100% optional and will only be used for the purpose of sending you your gift card.

Thanks for submitting!