Healthy Eating, Active Communities Student Nutrition … survey form-2.pdf · PLEASE DO NOT WRITE...

PLEASE DO NOT WRITE IN THIS AREA

Healthy Eating, Active CommunitiesStudent Nutrition and

Physical Activity Survey

Dear Student,

Thank you for taking the time to answer the following questions.

We are interested in learning what you think about physical activity and

nutrition. Please tell us your experiences and opinions. There are no right

or wrong answers to any of these questions.

All of your answers are anonymous. We do not want you to write your

name on the questionnaire. We hope you will be comfortable answering all

of these questions. You may skip any question if you choose to.

We think it will take you about 30 minutes to finish this questionnaire.

• Use number 2 pencil only.

• Make dark marks that fill the circle completely.

• Erase cleanly any mark you wish to change.

• Make no stray marks.

MARKING INSTRUCTIONS

✗✓Correct Mark Incorrect Marks

101 2 3 4 5 6 7 8 9 11 12 13 14 15 2016 17 18 19 21 22 23 24 25 26 3027 28 29

Section 1: Physical activity

You will see the words “physical activity” many times in this survey. Physical

activity is all kinds of movement and exercise. Some examples are dancing,

walking, biking, doing sports, yard work, or playing active games with friends.

You may do physical activities in a class, on a team, with a friend or your family,

or on your own.

Take a minute and think about the activities you did during

the past 7 days, then answer the questions below.

0days

1day

2-3days

4-5days

6-7daysa. Practice or play a team sport (like soccer, basketball,

baseball, volleyball, football, hockey, etc.) even if you

were practicing by yourself

b. Practice or play racquet sports like tennis, racquetball,

badminton, etc.

c. Play other ball games like kickball, handball, tetherball,

wall ball, etc.

d. Play other active games like capture the flag, tag, jump

rope, etc.

e. Walk quickly (for more than 10 minutes at a time)

f. Run (for more than 10 minutes at a time)

g. Practice martial arts, wrestling, boxing, kick boxing or a

similar sport

h. Do any kind of dance or gymnastics (include dance

classes, Dance Dance Revolution, Jazzercise, etc.)

i. Do yoga, Tai Chi, stretching, or similar exercise

j. Skate, skateboard, or ride a scooter (include ice skating,

rollerblading, etc.; do not include motorized scooters)

k. Swim, row or do other water sports

l. Ride a bicycle outdoors

m. Lift weights, do sit-ups, push-ups, pilates or other

activities to build muscles

n. Work out on other exercise equipment like an exercycle,

treadmill, or rock climbing wall

1. On how many of the past 7 days did you do the

following types of physical activities?

Please continue . . .

Think about the places where you have done physical activity not during school in the past week.

0

days

1

day

2-3

days

4-5

days

6-7

days

a. Go to a park, skatepark, outdoor sports field or ball court

where you were physically active outside

b. Go to a recreation or youth center, gym, indoor skate

park/rink, ball court, or other place where you were

physically active indoors (not including your home or

other people's homes)

c. Use a biking, walking, or jogging trail, path or track

d. Do any physical activity in the streets or yards of your

neighborhood

e. Take a class to do any type of exercise or physical activity

(such as swimming, gymnastics, martial arts, exercise

classes, etc.; do not include classes you did during school)

f. Play on a sports team of any kind (such as baseball,

soccer, track, swim, wrestling, etc.; do not include teams

during school)

g. Do any type of physical activity on school grounds notduring school hours

2. When you were not in school, on how many of the past 7 days did you do the following?

Now, think about what you did yesterday.

3. Yesterday, about how many minutes did you spend:

0 to 10minutes

About

10 to 20minutes

About

20 to 30minutes

Morethan30

minutes

a. Exercising or doing a physical activity that made

you sweat or breathe hard? (For example:

basketball, soccer, running, swimming laps, fast

bicycling, fast dancing, or similar activities)

b. Participating in a physical activity that did notmake you sweat or breathe hard? (For example:

fast walking, slow bicycling, shooting baskets,

skating, raking leaves, and mopping floors)



Section 2: Physical activity at school

4. Yesterday during school but not in PEclass, about how many minutes did you

spend doing physical activities that made

you sweat or breathe hard?


0 to 10 minutesAbout 10 to 20 minutesAbout 20 to 30 minutesMore than 30 minutes

5. How did you get home after school

yesterday?

I walkedI rode a bike, skateboard, skates, orscooter (not motorized)I rode in a carI rode the busOther

6. How did you get to school today?

I walkedI rode a bike, skateboard, skates orscooter (not motorized)I rode in a carI rode the busOther

7. How often are you excused from, or do you miss, PE for the following reasons?

Think about this school year when you answer the following questions.

a. I am excused from/miss PE for personal reasons (like

health, cultural, religious reasons)

b. I do other sports or exercise instead (like sports teams,

cheerleading, dance, etc.)

c. I am in the band or another type of club or class instead

d. Other __________________________________

Always Sometimes Never

8. Are you taking PE at school this year?

Yes, all yearYes, part of the yearNo, not at all (skip to question 11)

9. How much do you like your PE classes at

school?

I like PE a lotI like PE a little bitI don't like PE very muchI don't like PE at all

10. During PE class, how many minutes do you

usually spend exercising or moving around

(like when you stretch, run, dance, play

soccer, etc.)?

0 to 10 minutesAbout 10 to 20 minutesAbout 20 to 30 minutesMore than 30 minutes

Keep thinking about this school year when you answer the questions below.

Very

important Important

Not too

important

Not at all

important

a. Feel good

b. Do well in school

c. Look their best

d. Stay healthy

e. Have or make friends

11. How important do you think physicalactivity is for helping someone your age to:


Section 3: Your opinions about physical activity

Alwaysor almost

always OftenSome-times

Neveror almost

never

a. I enjoy being outdoors in my neighborhood

b. I feel safe when I am outdoors in my neighborhood

c. There are safe places in my neighborhood where I can

walk or ride a bike

d. My parents let me go outdoors in my neighborhood

e. In my neighborhood, there are outdoor places to do thekinds of physical activities I like to do (places like

parks, skate parks, sports fields, ball courts, etc.)

f. In my neighborhood, there are indoor places to do thekinds of physical activities I like to do (places like

youth and recreation centers, gyms, indoor skate parks

and ball courts, etc.)

g. I like to go to places in my neighborhood where they

offer physical activities

h. There are sports or other physical activities I would like

to do but they cost too much.

i. It is easy for me to get to the places where I can do the

physical activities that I like to do (such as classes, parks,

sports team practice or games, etc)

j. I do physical activities with my family

k. I do physical activities with my friends

l. I have plenty of time to do the physical activities I like to

do

12. How often are the following statements

true for you?


Lessthan 1

hour

1 to 2hours

2 to 3hours

3 to 4hours

Morethan 4hours

13. Yesterday about how many hours did you spend…..


a. watching movies or programs on a

TV or computer (include TV shows,

videos, DVDs, streaming video,

video clips, etc.)

b. playing video or computer games

(including handheld games such as

PSP, Gameboy, etc.)

c. doing other things on the computer,

like surfing the internet, blogging,

emailing, instant messaging, text

messaging, etc. (include time spent

with hand-held computers)

14. Last Saturday, about how many hours did you spend…

15. If you had a medical check-up (or physical exam) in the past year, did the doctor or nurse give

you any information about physical activity?

Yes and it was helpfulYes, but it was not helpfulNo

Congratulations-- you finished the physical activity questions!

Please continue on the next page.

I don't rememberI didn't have a medical check-up or physical examduring the past year

None at alla. watching movies or programs on a

TV or computer (include TV shows,

videos, DVDs, streaming video,

video clips, etc.)

b. playing video or computer games

(including handheld games such as

PSP, Gameboy, etc.)

c. doing other things on the computer,

like surfing the internet, blogging,

emailing, instant messaging, text

messaging, etc. (include time spent

with hand-held computers)

Lessthan 1

hour

1 to 2hours

2 to 3hours

3 to 4hours

Morethan 4hours

None at all


Now take a minute and think about what you did yesterday and answer the following questions.

17. Mark the circle for each of the places where you ate the following foods yesterday. If you

did not eat a certain food item, mark the first circle, “Did not eat”.

Please mark one or more answers for each food item.

Did

noteat

Ate

atschool

Ate

athome

Ate

at someotherplace

a. French fries or other fried potatoes

b. green salad

c. vegetables (Do not count salads or fried

potatoes)

d. fruit (Do not count fruit juice)

e. hot dogs, corn dogs, or hamburgers

f. pizza

g. fried chicken or chicken nuggets (Do notcount other types of chicken)

h. candy of any kind

i. breakfast bars, sports bars, granola bars,or other similar kinds of bars

j. ice cream or frozen yogurt

k. other sweets like cake, cookies, donuts,

pop-tarts, brownies, sweet rolls, pan dulce,

etc.

l. chips such as tortilla chips, potato chips,

corn chips, Cheetos, cheese puffs, or pork

rinds (Do not include baked chips)

m. baked chips, pretzels, crackers, or similar

snacks

Yesterday, did you eat…

16. Did you eat breakfast today?

Yes, I ate breakfast today No, I ate nothingthis morning

Section 4: Nutrition

No, but I had a snackthis morning


19. In the last 7 days, how many times did you eat or drink anything from a fast food restaurant?

(For example: McDonald's, Pizza Hut, KFC, Taco Bell, etc.).

0 times1 time

2-3 times4-6 times

Section 5: School Food

20. Did you eat the school breakfast yesterday? Yes No

21. Did you eat the school lunch yesterday? Yes No

a. Vending machine at school

b. Snack bar, cart, or store at school

c. Other sale or fundraiser at school

d. Friend or other student (not as part of a school sale or

fundraiser)

22. Yesterday at school, did you buy food or drink

from any of the following? (Please mark one or

more answers for each item.)

Yes, bought

during

school

Yes, bought

before or

after school

No, did not

buy or not

available

Did

notdrink

Drank

atschool

Drank

athome

Drank

at someotherplace

a. milk

b. diet drinks, such as diet soda, diet tea, etc.

c. regular soda or soft drinks

d. sports drinks such as Gatorade and Powerade

e. 100% fruit juice, such as orange juice, apple

juice or grape juice (Do not count fruit-flavored

drinks, Sunny Delight, aguas frescas, sports

drinks, etc.)

f. sweetened juice drinks or other sweeteneddrinks, such as Sunny Delight, Icees, Red Bull,

sweetened coffee or tea, aguas frescas, Koolaid,

etc.

g. water, out of the tap, from a water fountain or

from a bottle (or any other unsweetened water)

18. Mark the circle for each of the places where you drank the following beverages

yesterday. If you didn't drink an item at all, mark the first circle, “Did not drink”.

Please mark one or more answers for each beverage.

Yesterday, did you drink………..

7-10 timesMore than 10 times


a. Snack cart or food truck off campus

b. Fast food or other type of restaurant off campus

c. Store off campus

23. Yesterday, on your way to or from school orduring school, did you buy food or drink from any

of the following?(Please mark one or more answers

for each item.)


Veryimportant Important

Not tooimportant

Not at allimportanta. Chips (potato chips, cheese puffs,

corn chips, pork rinds, etc. Do not

include baked chips)

b. Low fat snacks (such as baked

chips, pretzels, crackers, etc.)

c. French fries

d. Regular soda or other sweetened

beverages

e. Diet soda or other diet drinks

f. Sports drinks

g. Fresh fruit

h. Green salad

i. Other vegetables

j. Candy

k. Ice cream, frozen yogurt and other

frozen desserts

l. Other sweets like cookies, cakes,

brownies, donuts, etc.

24. How important is it to you to be able to buy the following food items at school?

Yes, bought

during

school

Yes, bought

before or

after school

No,did not

buy

a. The school lunch is healthy

b. The school lunch tastes good

c. The school breakfast is healthy

d. The school breakfast tastes good

e. The foods that are sold in places like vending machines,

snack bars, carts or stores at my school are healthy

f. The foods that are sold in places like vending machines,

snack bars, carts or stores at my school taste good

25. How often are these statements true in your opinion?

Alwaysor almost


Neveror almost

never


Section 6: Your opinions about nutrition

a. Feel good

b. Do well in school

c. Look their best

d. Stay healthy

26. How important do you think good nutritionis for helping someone your age to:

Veryimportant Important

Not tooimportant

Not at allimportant

a. There are healthy snack foods that I like to eat at home

b. I eat dinner at home with my family

c. In my neighborhood it is easy to find a place to buy a piece

of fruit or vegetables

d. In my neighborhood it is easy to find a place to buy

healthy snacks

e. In my neighborhood it is easy to find a place to buy candy,

soda and other sweets

f. It is easy to buy healthy foods at fast food or other

affordable restaurants in my neighborhood

g. Healthy foods taste good

h. Healthy foods cost too much

27. How often are these statements true in your opinion?

Alwaysor almost


Neveror almost

never


Mostdays

SomeDays

Seldomor

Never

I don'twatch

TV

a. Fruits or vegetables

b. Sodas or other sweetened beverages

c. Candy or other sweets

d. Video or computer games

e. Where or how to be physically active

f. Where or how to get healthy food

31. How often do you see ads on TV for the

following?


28. During the past 12 months have you

been in a class where you learned about

how to make or choose healthy foods?

Yes, and it was helpfulYes, but it was not helpfulNo

29. If you had a medical check-up (or physical

exam) in the past year, did the doctor or

nurse give you any information about

healthy eating?

Yes and it was helpfulYes, but it was not helpfulNo I don't rememberI haven't had a medical check-up orphysical exam during the past year.

30. Do you participate in a group or program working to improve nutrition or physical activity at

your school or in your community?

Yes No, but I would like to No, this doesn't interest me

Manytimes

each day

Mostdays

SomeDays

Seldomor

Never

a. Fruits or vegetables

b. Sodas or other sweetened beverages

c. Candy or other sweets

d. Video or computer games

e. Where or how to be physically active

f. Where or how to get healthy food

32. How often do you hear radio ads or seebillboards, posters, signs, etc. about the

following? (do not include TV commercials)

Manytimes

each day

Just one more section to go!

Section 7: A little information about you

33. How do you describe yourself? (Mark all

that apply.)

Asian American Indian or Alaska NativeHawaiian or Pacific Islander Black or African AmericanHispanic or Latino/LatinaWhite or CaucasianOther

38. Girls, please mark the circle of the picture you think is most like your body shape.

Thank you, girls, you're finished!

39. Boys, would you say that you are:

Less active than most boys your ageAbout as active as most boys your ageMore active than most boys your age

40. Boys, please mark the circle of the picture you think is most like your body shape.

Thank you so much for completing this survey!PLEASE DO NOT WRITE IN THIS AREA

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36. Are you:

Female (Girl) (go to question # 37)Male (Boy) (skip to question # 39)

37. Girls, would you say that you are:

Less active than most girls your ageAbout as active as most girls your ageMore active than most girls your age

35. What grade are you in?

7th 9th

34. English is the language used in my home:

All of the timeMost of the time

Some of the timeRarely

Healthy Eating, Active Communities Student Nutrition … survey form-2.pdf · PLEASE DO NOT WRITE...

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