screener (v2)

Intro -


Compare how much you go out to how much you eat at home?

1) most of the time
2) a lot of the time
3) every once in a while
4) I go out a lot /

About how long does it take to make a typical meal?

1) less than 5 minutes (CLOSE)
2) 5-10 minutes (CLOSE)
3) 10-20 minutes
4) 20-30 minutes
5) more than 30 minutes

How much preparation is involved in a typical meal?

1) hardly any prep (CLOSE)
2) not very much prep (CLOSE)
3) some prep
4) lots of prep

What type of foods do you eat in a typical meal?

1) mostly instant meals
2) mostly from a box or can
4) mostly fresh ingredients

How do feel about cooking?

1) I hate cooking
2) I don't mind cooking
3) I frequently like cooking
4) I love cooking

// drop if they haven't scored high enough

Where do you shop for food?

1) large discount stores like Wal-Mart and Target
Bulk food stores like Costco and Sam’s Club
2) grocery stores like Jewel or Dominick's
3) small family owned grocery stores
4) health food stores
5) organic food stores like Whole Foods
6) local markets, such as a farmer's market
7) online food services
8) other______


on a scale of 1-5, rate what you find most important to least important about your food (no answer can be rated the same)
Quality
Speed
Health
Cost
Ethical Concerns

Select the types of food you eat:
Fish
Meat
Vegetables
Fruits
Dairy
Grains

Name 3 meals you’ve cooked in the past month that you might consider “gourmet”:


Do you have any medical conditions that affect your eating habits?

What is your gender?
Male
Female

How old are you?
1) under 18
2) 18-21
3) 21-25
4) 25-30
5) 30-40
6)40-50
7) 50 or older

What is the highest level of education you have completed?
Some high school
High school graduate
Some college
College graduate
Post graduate courses or degree

Which of the following best describes your total annual household income?
under $30,000
between $30,000 and $50,000
between $50,000 and $100,000
between $100,000 and $200,000
$200,000 or more

What is your current employment status? Are you . . .
A full-time homemaker
A full-time student
Employed part time
Employed full time
Retired
Currently seeking employment

First and Last Name (open)

Email Address (open)

Primary Phone (open)

Other Phone (optional)

Where do you live?
Within the city of Chicago
In the suburbs of Chicago
Outside of Chicago
Another city altogether

What is your zip code? (open)