
Article 1 
The structured survey on end recipients referred to in Article 17(4) of Regulation (EU) No 223/2014 shall be carried out in accordance with the template set out in the Annex.
Article 2 
This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.
This Regulation shall be binding in its entirety and directly applicable in all Member States.Done at Brussels, 18 April 2016.
For the Commission
The President
Jean-Claude JUNCKER
ANNEX
Name of the interviewer[full name of the interviewer. If several people carry out the interview, all of them should be noted here]Place[address where the survey is carried out]Organisation[name of the partner organisation from which the end recipient received assistance]Date[date of the survey in format dd/mm/yyyy]Time[time of the survey in format hh:mm]

A. 


A1. Daily Weekly Monthly Other
Food packages    (specify)
Meals    (specify)
Goods distributed to children    (specify)
Goods distributed to the homeless    (specify)
Other (to be specified) [specify type] [specify type] [specify type] [specify type and period]




A2.Advice on food preparation and storage, cooking workshops, educational activities to promote healthy nutrition, or advice on how to reduce food waste 
Personal cleanliness advice 
Redirection to competent services (e.g. social/administrative) 
Individual coaching and workshops 
Psychological and therapeutic support 
Advice on managing a household budget 
Other (to be specified) [Text box to be filled in]
None 



A3.Yes No
 



A3a.Food packages 
Meals 
Goods distributed to children 
Goods distributed to the homeless 
Other goods [specify type]

B. 


B1.Male Female
 



B2.15 or less 16-24 25-49 50-64 65 or above Does not wish to answer Does not know or does not understand the question
      



B3.Yes No Does not wish to answer Does not know or does not understand the question
   



B4. Yes No Does not wish to answer Does not know or does not understand the question
Food packages    
Meals    
Layette (baby essentials)    
School bags    
Stationery, exercise books, pens, painting equipment and other equipment required in school (non-clothes)    
Sports equipment (sport shoes, leotard, swimsuit, etc.)    
Clothes (winter coat, footwear, school uniform, etc.)    
Sleeping bags/blankets    
Kitchen equipment (pots, pans, cutlery, etc.)    
Household linen (towels, bedclothes)    
Hygiene articles (first aid kit, soap, toothbrush, disposable razor, etc.)    
Other categories of goods [Text box to be filled in]



B5.Yourself Other people in your household Does not wish to answer Does not know or does not understand the question
   

If the answer to question B5 is ‘Yourself’ only, skip question B6.



B6. Male Female
5 or less  
6-15  
16-24  
25-49  
50-64  
65 or above  
Does not wish to answer  
Does not know or does not understand the question  



B7.Yes No Does not wish to answer Does not know or does not understand the question
   

If the answer to question B7 is ‘Yes’, ‘Does not wish to answer’ or ‘Does not know or does not understand the question’, then go directly to question B9.



B8.Daily Weekly Monthly Other Does not wish to answer Does not know or does not understand the question
     



B9.Tomorrow Within next week Within next month Other Does not wish to answer Does not know or does not understand the question
     



B10.Yes No Does not wish to answer Does not know or does not understand the question
   



B10a.Need to get some papers from some national, regional or local office 
Need to travel a long distance 
Psychological hurdles 
Other (to be specified) [Text box to be filled in]
Does not wish to answer 
Does not know or does not understand the question 



B11.Yes Partially No Does not wish to answer Does not know or does not understand the question
    



B11a.Insufficient quantity of food/goods 
Insufficient frequency of food/goods distribution 
Insufficient quality of food/goods 
Other type of assistance required (to be specified) [Text box to be filled in]
Does not wish to answer 
Does not know or does not understand the question 



B12.Yes No Does not wish to answer Does not know or does not understand the question
   



B13.Yes No Does not wish to answer Does not know or does not understand the question
   



B13a. Yes Does not wish to answer Does not know or does not understand the question
Food packages   
Meals   
Layette (baby essentials)   
School bags   
Stationery, exercise books, pens, painting equipment and other equipment required in school (non-clothes);   
Sports equipment (sport shoes, leotard, swimsuit, etc.)   
Clothes (winter coat, footwear, school uniform, etc.)   
Sleeping bags/blankets   
Kitchen equipment (pots, pans, cutlery, etc.)   
Household linen (towels, bedclothes)   
Hygiene articles (first aid kit, soap, toothbrush, disposable razor, etc.)   
Other [Text box to be filled in]



B14.Advice on food preparation and storage, cooking workshops, educational activities to promote healthy nutrition, or advice on how to reduce food waste 
Personal cleanliness advice 
Redirection to competent services (e.g. social/administrative) 
Individual coaching and workshops 
Psychological and therapeutic support 
Advice on managing a household budget 
Other (to be specified) [Text box to be filled in]
Does not wish to answer 
Does not know or does not understand the question 



B15.Very useful Somewhat useful Not very useful Not useful at all Does not wish to answer Does not know or does not understand the question
     



B16.Yes No Does not wish to answer Does not know or does not understand the question
   



B17.Yes No Does not wish to answer Does not know or does not understand the question
   



B18.Yes No Does not wish to answer Does not know or does not understand the question
   



B19.Yes No Does not wish to answer Does not know or does not understand the question
   



B20.Yes No Does not wish to answer Does not know or does not understand the question
   



B21.Yes No Does not wish to answer Does not know or does not understand the question
   



B22.Yes No Does not wish to answer Does not know or does not understand the question
   



B23.Yes No Does not wish to answer Does not know or does not understand the question
   



B23a.Owned or rented dwelling or house, either alone or with the family 
Shared dwelling with friends and other people 
Institutional long-term home (home for elderly, single mothers, asylum seekers) 
Sheltered housing 
Ruined house or slum 
Mobile home/caravan 
Refugee camp 
Other (to be specified) [Text box to be filled in]
Does not wish to answer 
Does not know or does not understand the question 
