Households (adults 18 and up); Mail screener

Who should complete this survey?

• An adult 18 years old or older, living or staying at this address for more than 2 months, who is knowledgeable about this home should complete this survey.

• Please do not have an adult who is only visiting the home temporarily complete this survey. When answering the questions, please do not include anyone who is away at school or away in the military or anyone who is visiting temporarily.

If NO ONE in the household Please fill in or mark an X in the circle below and
meets these criteria return the survey in the enclosed envelope

• No one in the household
  meets these criteria

Survey Instructions

Mark your response by filling in the area () or marking an X ().

The first few questions will help us better understand who lives in your home.

1. Including you, how many adults 18 years old or older live or stay at this address?

• INCLUDE all adults 18 years old or older who are living or staying here for more than 2 months.

• INCLUDE all adults 18 years old or older staying here who do not have another place to stay, even if they are here for 2 months or less.

• DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

• 1

• 2

• 3

• 4

• 5

• 6

• 7 or more

2. Including you, how many adults 18 years old or older living or staying in this home are in each age group? (Mark an answer for each row)

	Number of Adults Including You
	0	1	2	3 or more
Age 18-24
Age 25-54
Age 55+

2. Are there any children who are less than 18 years old who live or stay at this address?

• Yes

• No

2. Which best describes this home? (Mark only one)

• A trailer or mobile home

• A one-family house detached from any other house

• A one-family house attached to one or more houses

• An apartment

• Something else

2. Is this home . . .

• Owned by you or someone in your household

• Rented

• Occupied without payment of rent

2. Which of the following languages are spoken in this home? (Mark all that apply)

• English

• Spanish

• Another language or languages

The next two questions ask about computers, the internet, and media.

2. In this home, do you or any member of this household own or use any of the following types of computers? (Mark all that apply)

• Desktop or laptop computer

• Smartphone

• Tablet computer (such as, an iPad, Surface Pro, Galaxy Tab)

• Some other type of computer

2. In this home, do you or any member of this household have access to the internet?

• Yes

• No

The next few questions ask about food shopping.

2. In a typical month, how many times per month do you go food shopping for your household?

• 0 times

• 1 or 2 times

• 3 to 5 times

• 6 to 9 times

• 10 or more times

2. Have you ever ordered food online?

• Yes

• No

2. Thinking about the next 12 months, how likely are you to order food online?

• Extremely likely

• Likely

• Unlikely

• Extremely unlikely

2. In the past 12 months, did you or any member of this household receive benefits from the Food Stamp Program or the Supplemental Nutrition Assistance Program (SNAP)?

• Yes

• No

These next few questions ask about health.

2. Would you say that in general your health is…?

• Excellent

• Very good

• Good

• Fair

• Poor

2. Including you, how many adults between the ages of 18 and 24 living or staying in this home now smoke cigarettes every day or some days?

• 0

• 1

• 2

• 3 or more

2. Including you, how many adults between the ages of 25 and 54 living or staying in this home now smoke cigarettes every day or some days?

• 0

• 1

• 2

• 3 or more

2. Including you, how many adults age 55 or older living or staying in this home now smoke cigarettes every day or some days?

• 0

• 1

• 2

• 3 or more

These last few questions ask about the people living at this address.

2. Including you, how many of the adults 18 years old and older living or staying in this home are male and how many are female? (Mark an answer for each row)

	Number of Adults Including You
	0	1	2	3 or more
Male
Female

2. Including you, how many adults 18 years old and older living or staying in this home…
   (Mark an answer for each row)

   	Number of Adults Including You
   	0	1	2	3 or more
   Do not have a high school diploma or equivalent (GED)
   Have a high school diploma/GED but did not attend college
   Attended some college but do not have a college degree
   Have an Associates, Bachelor’s, graduate or professional degree

3. Including you, how many of the adults 18 years old or older who live or stay in this home are Hispanic, Latino or of Spanish origin?

• 0

• 1

• 2

• 3 or more

2. Including you, how many adults 18 years old or older living or staying in this home are…
   (Mark an answer for each row)

	Number of Adults Including You
	0	1	2	3 or more
White
Black or African-American
Asian
Other

You have reached the end of the survey. Thank you for your time.

Please return this survey in the postage-paid, addressed envelope we have provided.

Or mail to:

RTI International

Research Operations Center

5265 Capital Boulevard

Raleigh, NC 27690-1653

Data Capture 0213772.003.001

If you have questions, please call 1-800-328-0281 (ext. 21860)

OMB No: 0910-#### Expiration Date: ##/##/20##

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 10 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

RIHSC No. 17-###CTP

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Griggs, Ashley
File Modified	0000-00-00
File Created	2021-01-20