1.

What is the zip code (five-digit) where you live? ________________________________________________

2. Indicate the number of people in your household in each age group that you purchase food for regularly.
_____ 0 - 5 years _____ 6 - 17 years _____ 18 - 25 years _____ 26 - 64 years _____ 65 and older

3. On a weekly basis, where do you get most of the food prepared at home? (Check all that apply)
□ Church, charity, food pantry □ Gas station, convenience store, or dollar store
□ Community garden □ Grocery store, super center, warehouse club
□ Home delivery (Schwan’s, Amazon, etc.) □ Farmers’ market, farm stand, or Community Supported Agriculture program (CSA)
□ Other _______________________________________________________________________________________________

4. What are the main reasons for getting food from these sources? (Check up to 3)
□ Easy/Habit □ Healthy food □ Location □ Price □ Quality
□ Other (please specify) _______________________________________________________________________________________________

5. Where do you eat away from home? (Check all that apply)
□ Cafeteria (including school, workplace, or hospital cafeterias) □ Fast food restaurant □ Family or friends □ Restaurant or diner
□ Church or faith organizations □ Community centers or organizations (including senior congregate meals)
□ Other _________________________________________ □ N/A

6. How satisfied are you with healthy food that is currently available in your community?
Extremely satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Extremely dissatisfied
Access (it is easy to get healthy food)
Price (amount I pay for healthy food)
Quality (healthy food at the store looks
& tastes good)
Variety (many choices of healthy food)

7. How do you usually get to the store to buy or receive food?

□ Drive own car □ Home delivery □ Public transportation □ Ride with someone else
□ Taxi, Uber, other paid service □ Walk or bike □ Other (please specify) ___________________________________

8. How far do you usually travel to buy food?

□ Less than 1 mile □ 1 - 5 miles □ 6 - 10 miles □ More than 10 miles

9. On most days how many servings of:

0 1 2 3 4 5 or more N/A
Fruits do you eat? (One medium apple, orange, or banana, half cup chopped fruit, or about the size of a small fist)
Veggies do you eat? (One cup leafy veggies, half cup raw/cooked veggies, or about the size of a small fist)
Whole grains do you eat? (One cup of ready to eat cereal; half cup of cooked cereal, pasta or rice; a slice of bread)

10. What makes it difficult for you to eat fruits and veggies each day? (Check all that apply)
□ Don’t have utensils or cooking equipment to prepare □ Don’t know how to prepare fruits and vegetables □ They’re too expensive
□ Don’t like fruits or vegetables □ Lack of time to prepare meals at home □ Store doesn’t have them
□ Lack transportation to buy affordable produce □ Poor-quality fresh fruits and veggies where I shop □ Nothing
□ Other _________________________________________________________________________________________________________________

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11. Within the past 12 months our household worried about food running out, before we got money to buy more.
□ Never □ Sometimes □ Often true

12. Within the past 12 months the food our household bought didn’t last, and we didn’t have money to get more.
□ Never □ Sometimes □ Often true

13. How often do you drink sugar sweetened beverages (soda, juice, energy drink, latte, etc.)
□ Often □ Sometimes □ Rarely □ Never

14. How often do you use nutrition information (i.e. posted calories) that is available in restaurants?
□ Often □ Sometimes □ Rarely □ Never

15. How interested are you in learning how to:

Very Interested Somewhat Interested Not Interested N/A
Make healthy food choices
Help children make healthier food choices
Prepare healthy meals
Access food assistance programs
Grow food
Participate in a community garden
Purchase healthy foods on a budget

16. What is your gender?

□ Female □ Male □ Prefer not to answer □ Other/Additional gender category _______________________________

17. What is your age?

□ 18 - 29 years □ 30 - 49 years □ 50 - 64 years □ 65+ years

18. Race
□ American Indian or Alaska Native □ Asian □ Black/African American □ Caucasian/White
□ Native Hawaiian or Pacific Islander □ Two or more races □ Other ________________________________________________

19. Ethnicity
□ Hispanic or Latino □ Middle Eastern or Northern African □ None of the above

20. What is your primary language spoken at home?

□ Arabic □ English □ Spanish □ Other ________________________________________________

21. Highest level of education

□ Less than high school diploma or GED □ High school diploma or GED □ Some college or technical training
□ 2-year college degree □ 4-year college degree □ Graduate degree

22. About how much is your yearly household income before taxes (not including public assistance or SNAP benefits)?
□ Less than $10,000 □ $10,000 to $14,999 □ $15,000 to $24,999 □ $25,000 to $34,999
□ $35,000 to $49,999 □ $50,000 to $74,999 □ $75,000 to $99,999 □ $100,000 to $149,999
□ $150,000 to $199,999 □ $200,000 or more

For more information about Oakland County’s Food Policy Council, please visit www.oakgov.com/ECHO.

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