Community Grocery Questionnaire

Work with partners in your community to learn more about community food resources to improve access to healthy foods. This questionnaire is adapted from the University of Illinois Extension Health Equity Achieved Together (HEAT) project.

This questionnaire will take 5 minutes to complete.




Check all the places where you can get groceries within a 15-minute travel time (one way) of where you live:

I cannot buy groceries within a 15-minute travel distance of my home.
At a regular chain grocery store with fresh and packaged food items (Kroger, Schnucks, Aldi, Save-A-Lot).
At a large retail store like Walmart or Target.
At a small local grocer, deli, or meat shop (Local Grocer Name, Local Deli Name, etc.)
At a convenience store, gas station, or pharmacy with fresh food (fruits, vegetables, meats, dairy, eggs)
At a convenience store, gas station, or pharmacy with ONLY packaged items (no fresh food)
At a Dollar Store (Dollar General, Family Dollar)
At a farmer's market or farm/produce stand.
At a food pantry

If you buy groceries outside of a 15-minute traveling distance from the place where you live, how long are you traveling (one way)?

16 - 30 minutes
31 - 60 minutes
Over an hour
I don't buy groceries outside of a 15-minute traveling distance

Please check all programs you've seen around your community that people participate in (check all that apply):

Free or reduced-price school lunch or breakfast
SNAP-Supplemental Nutrition Assistance Program (LINK)
WIC
CSFP (Senior Food Box)
Senior meal site
Weekend food backpack program
None of these

How often do you buy groceries outside of [state/county]??

Never
Once per week
2-3 times per month
Once per month

How often do you buy groceries online?

Never
Once per week
2-3 times per month
Once per month

Thinking of the place where your household gets most of its groceries, how often are these foods available?

Never Sometimes Always
Fresh fruits and vegetables
Fresh meats
Frozen fruits and vegetables
Whole grains and breads
Frozen meats
Canned and boxed foods
Dairy and eggs
Other healthy food options

How important is it that the place where your household gets groceries has the features listed below?

Not at all important Somewhat important Very important
Accepts SNAP/LINK or WIC benefits
Offers fresh produce
Offers fresh meats, dairy and eggs
Is a regular grocery store (not just a convenience store)
Is close to your home (within 15 minutes)
Offers packaged foods
Offers additional goods (household items, money services, pharmacy, etc)
Offers organic foods
Has special dietary options (such as vegan, gluten-free, kosher, low-sodium, etc.)
Offers locally produced foods
Has special dietary options (such as vegan, gluten-free, kosher, low-sodium, etc.)
Is open early
Is open late
Is a national chain or major retail store
Has online ordering or store pickup/delivery

In a normal month, how much money does your household spend on groceries?

$1-$100
$101 - $200
$201 - $300
$301 - $400
$401 - $500
$500+

When you or someone in your household buys groceries, how do you usually get there? (Check all that apply)

I drive my own car
I ride in a friend or family member's vehicle
I walk
I ride the bus/public transit
I ride my bike
I pay for a ride service (Uber/Lyft/Taxi)
Other: __________________________

10. How likely is it that you or someone in your household would get groceries from the places below IF they were available in your community?

Not Likely Somewhat Likely Likely Very Likely Extremely Likely
A locally owned grocery store
A chain grocery store
A farmerâ??s market or farm stand
A co-op (member owned) grocery store
A food pantry
A mobile market
A dollar store (Dollar General, Family Dollar)
A grocery delivery service
A convenience store, gas station, or pharmacy

What makes it difficult for you to eat fruits, vegetables, or lean meats? (check all that apply)

Not available in my community
It is not a challenge for me to eat these foods
Cost
Limited transportation
Available hours of food outlets
Distance to store
It takes too long to cook or prepare these foods
Limited access to kitchen or kitchen supplies to prepare food
Not sure how to prepare/cook meals with fruits, vegetables, or lean meats
I don't like these foods
Other: ___________________________

What is your zip code where you live/reside?

What is your zip code where you work?

Do you work remotely/telecommute?

Yes
No

What is your age?

Under 18
18-24
25-34
35-44
45-54
55-64
65+

What is your household's total annual income?

Under $20,000
$20,001 - $40,000
$41,001 - $60,000
$60,001 - $80,000
$80,001 - $100,000
$100,001+

15. How many adults above the age 18 (including you) live in your household?

How many children below the age of 5 live in your household?

What is your gender?

Male
Female
Transgender Male
Transgender Female
Not Listed: ________________
Prefer not to answer

Please describe your race.

Asian
Black/African American
Caucasian
Hispanic/Latino/Latinx
American Indian or Alaskan Native
2 or more races
Other (please specify):

What is your ethnicity?

Hispanic/Latino/Latinx
Non-Hispanic/Non-Latino/Non-Latinx
Prefer not to answer