Compendium of Surveys (to assess fruit and vegetable consumption)

COMPENDIUM OF SURVEYS.................................................................................................................. 1FRUIT AND VEGETABLE TOOLS .......................................................................................................... 5Measures of Consumption for Adults .................................................................................................. 5Measures of Consumption for Adults .................................................................................................. 6Food Behavior Checklist - Food Stamp Program............................................................................... 8Food Behavior Checklist - Food Stamp Program (Spanish) ............................................................ 9UCCE Food Behavior Checklist.......................................................................................................... 10Fruit and Vegetable Checklist ............................................................................................................. 11NCI All-Day Screener ........................................................................................................................... 12NCI By Meal Screener (Thompson, et al.)......................................................................................... 15Fruit and Vegetable Module (BRFSS) ............................................................................................... 23Measures of Consumption for Children ............................................................................................ 24The Day in the Life Questionnaire (7-9 years).................................................................................. 27Day in the Life Questionnaire (9-11 years) ....................................................................................... 31California Healthy Kids Survey (CHKS)............................................................................................. 41School Physical Activity and Nutrition Project (SPAN).................................................................... 42Youth Risk Behavior Survey (YRBS) ................................................................................................. 43Food Recognition Form (Cullen, et al.).............................................................................................. 45Food Frequency Questionnaire .......................................................................................................... 48Availability Surveys ................................................................................................................................ 64Availability Survey – Fruit, Juice & Vegetables at School (Network) ............................................ 65Availability Survey – Fruit, Juice & Vegetables At Home (Hearn, et al.) ...................................... 66Availability Survey (Hearn) .................................................................................................................. 66School and Idea Resource Kit.............................................................................................................. 67Harvest of the Month Survey................................................................................................................ 76Network Youth Survey and Network High School Surveys.......................................................... 83Network Youth Survey ........................................................................................................................... 87Encuesta para Jóvenes.......................................................................................................................... 94Network High School Survey.............................................................................................................. 101Nutrition Education Survey................................................................................................................. 108Food Preferences Survey.................................................................................................................... 121

Food Security Surveys......................................................................................................................... 125Food-Security/Hunger Core Module ................................................................................................ 127California Women’s Health Survey Food Adequacy Module........................................................ 133Short Form of the 12-month Food Security Scale - Questionnaire ............................................. 137Knowledge, Awareness & Beliefs Surveys..................................................................................... 138General Knowledge (Reynolds, Hoelscher).................................................................................... 140Hawthorne Unified School District (Russell) ................................................................................... 141Fruit and Vegetable Inventory............................................................................................................ 142Norms Surveys for Children ............................................................................................................... 144Social Norms (Baranowski, et al.) .................................................................................................... 145Family Norms (Reynolds, et al.) ....................................................................................................... 145Outcome Expectations Surveys for Children................................................................................. 146Outcome Expectations for Eating FVs (Reynolds)......................................................................... 147Outcome Expectations for Eating FVs (Baranowski, et al.).......................................................... 148Self-Efficacy Surveys for Children.................................................................................................... 149Self-Efficacy Survey – Eating, Asking, Preparing FVs (Reynolds, et al.) ................................... 150Exámen de Eficacia Propia–Comiendo, Preguntando, Preparando Frutas y Vegetales ......... 151Self-Efficacy Survey - Eating FVs (Baranowski, et al.).................................................................. 153Self-Efficacy Survey - Asking and Shopping for FVs (Baranowski, et al.).................................. 154PHYSICAL ACTIVITY TOOLS.............................................................................................................. 155Physical Activity Surveys for Adults................................................................................................ 156Physical Activity Survey (BRFSS) .................................................................................................... 1587-Day Physical Activity Recall (Sallis, et al.)................................................................................... 159Physical Activity Surveys for Children and Teens ....................................................................... 161Physical Activity Survey (YRBS)....................................................................................................... 162Physical Activity Preferences for Children and Adults ............................................................... 164Physical Activity Preferences Survey (Sherwood, et al.) .............................................................. 165Self Efficacy for Physical Activity Survey for Adults................................................................... 166Self-Efficacy for Physical Activity Survey (Sallis, et al.) ................................................................ 167Social Support for Physical Activity Survey for Adults............................................................... 168Social Support From Family & Friends for Physical Activity Survey (Sallis, et al.) ................... 169Demographic Information.................................................................................................................... 170

FRUIT AND VEGETABLE TOOLS

Measures of Consumption for AdultsTarget behaviorFruit and vegetable consumption.What is being measured?This section includes six measures of fruit and vegetable consumption foradult populations. The first two are the Food Behavior Checklist, the UCCE FoodBehavior Checklist and the Fruit and Vegetable Checklist. They are followed bythe NCI “by meal” screener and NCI “All-Day” screener. The final survey is theBRFSS fruit and vegetable module.The 16-item Food Behavior Checklist contains questions about fruit andvegetable consumption, shopping and preparation, and one about food security.The instruction manual is included after the survey instrument. The survey is alsoavailable in Spanish. The UCCE Food Behavior Checklist is also available whichincludes questions about cups of fruits and vegetables instead of servings. Forthe instruction manual for this survey please refer to the Food Behavior Checklistmanual.The Fruit and Vegetable Checklist is a shortened version of the FoodBehavior Checklist using only seven questions that focus specifically on fruit andvegetable intake. Both surveys have been validated. The instruction manual isincluded after the survey instrument.The NCI “all day” screener measures frequency and portion size of ninefruits and vegetables. It was validated by Thompson, et al. (2002) by comparingthe amount of fruit and vegetable intake on the All-Day screener to four 24-hourdietary recalls administered via telephone over a one year period. The surveyswere completed by 202 men and 260 women aged 20 to 70 years. The mediandaily servings reported in the 24-hour recalls were 5.8 for men and 4.2 forwomen compared to 5.0 for both genders on the All-Day screener. Theestimated correlations between the All-Day screener and 24-hour recalls were0.66 for men and 0.51 for women.The “By-Meal” screener measures the consumption of fruit and vegetablesother than potatoes, salad, and beans, by time of day. Thompson, et al.’svalidation study (2002) found that the median daily servings reported in the By-Meal screener was 5.5 (men) and 5.4 (women) as compared to 5.8 (men) and4.2 (women) in the 24-hour recalls. Correlations between the By-Meal screenerand 24-hour recalls were 0.67 for men and 0.53 for women.The telephone-administered Behavioral Risk Factor Surveillance Survey(BRFSS) tracks major health risks among Americans. Serdula and colleagues(1993) assessed its validity among five populations with diverse characteristics.Spearman correlation coefficients between the BRFSS items and other foodfrequency questionnaires ranged from 0.47 to 0.57 in four sites. Correlationcoefficients for the BRFSS items and diet records were 0.54 and 0.29 in two sitesand 0.46 with 24-hour recalls. Overall, the moderate correlations between theFood Behavior Checklist 6

BRFSS items and most of these criterion measures suggest it is a suitablemeasure of fruit and vegetable intake.Who is the target audience?Adults aged 20-70 yearsAdditional informationThe surveys, which have been validated, should not be modified. Theyshould be used to show that the intervention produced a change in fruit andvegetable intake.ReferencesTownsend MS, Kaiser LL, Allen LH, Joy AB, Murphy SP. Selecting Items for AFood Behavior Checklist for a Limited Resource Audience. Journal of NutritionEducation and Behavior. 2003; 35:69-82National Cancer Institute. 2002. Fruit and Vegetable screeners. [Online]Available: http://riskfactor.cancer.gov/diet/screeners/fruitveg/instrument.html.Thompson, F. E., A. F. Subar, et al. Fruit and vegetable assessment:performance of 2 new short instruments and a food frequency questionnaire. JAm Diet Assoc 2002; 102(12): 1764-72.Centers for Disease Control and Prevention. 2002. Behavior Risk FactorSurveillance System Core Section 4: Fruits and Vegetables. [Online] Available:http://www.cdc.gov/brfss/questionnaires/pdf-ques/2002brfss.pdf.Serdula M, Coates R, Byers T, et al. Evaluation of a brief telephonequestionnaire to estimate fruit and vegetable consumption in diverse studypopulations. Epidemiology 1993; 4:455-463.Food Behavior Checklist 7

Food Behavior Checklist - Food Stamp ProgramFull survey available from http://townsendlab.ucdavis.edu/Food Behavior Checklist 8

Food Behavior Checklist - Food Stamp Program (Spanish)Full survey available from http://townsendlab.ucdavis.edu/Food Behavior Checklist (Spanish) 9

UCCE Food Behavior ChecklistFull survey available from http://townsendlab.ucdavis.edu/UCCE Food Behavior Checklist 10

Fruit and Vegetable ChecklistFull survey available from http://townsendlab.ucdavis.edu/Fruit and Vegetable Checklist 11

NCI All-Day ScreenerNCI All Day Screener 12

NCI All Day Screener 13

NCI All Day Screener 14

NCI By Meal Screener (Thompson, et al.)Think about what you usually ate last month.Please think about all the fruits and vegetables that you ate last month. Include those that were:— raw and cooked,— eaten as snacks and at meals,— eaten at home and away from home (restaurants, friends, take-out), and— eaten alone and mixed with other foods• Report how many times per month, week, or day you ate each food, and if you ate it, how much you usually had.• If you mark "Never" for a question, follow the "Go to" instruction.• Choose the best answer for each question. Mark only one response for each question.1. Over the last month, how many times per month, week, or day did you drink 100% fruit juice such as orange, apple, grape, orgrapefruit juice? Do not count fruit drinks like Kool-Aid, lemonade, Hi-C, cranberry juice drink, Tang, and Twister. Include juiceyou drank at all mealtimes and between meals.1 2 3 4 5 6 7 8 9 10 Never(Go toquestion2)1-3 timesLastmonth1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day1a. Each time you drank 100% juice, how much did you usually drink?1 2 3 4 Less than ¾ cup ¾ to 1¼ cup 1¼ to 2 cups More than 2 cups(less than 6 ounces) (6 to 10 ounces) (10 to 16 ounces) (more than 16 ounces)NCI by Meal Screener 15

2. Over the last month, how often did you eat lettuce salad (with or without other vegetables)?1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslastmonth1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day2a. Each time you ate lettuce salad, how much did you usually eat?1 2 3 4 About ½ cup About 1 cup About 2 cups More than 2 cups3. Over the last month, how often did you eat French fries or fried potatoes?1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day3a. Each time you ate French fries or fried potatoes, how much did you usually eat?1 2 3 4 Small order or less Medium order Large order Super Size order or more(About 1 cup or less) (About 2 cups) (About 1 ½cups) (About 3 cups or more)4. Over the last month, how often did you eat other white potatoes? Count baked, boiled, and mashed potatoes, potato salad,and white potatoes that were not fried.1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper dayNCI by Meal Screener 16

4a. Each time you ate these potatoes, how much did you usually eat?1 2 3 4 1 small potato or less 1 medium potato 1 large potato 2 medium potatoes or more(½ cup or less) (½ to 1 cup) (1 to 1½ cups) (1½ cups or more)5. Over the last month, how often did you eat cooked dried beans? Count baked beans, bean soup, refried beans, pork andbeans and other bean dishes.1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day5a. Each time you ate these beans, how much did you usually eat?1 2 3 4 Less than ½ cup ½ to 1cup 1 to 1½ cups More than 1½ cupsNow, divide your waking hours into three time periods:• MORNING• LUNCHTIME AND AFTERNOON• SUPPERTIME AND EVENINGPlease think about the foods you ate during each of those time periods over the last month.MORNING6. Think about all the foods you ate at your morning meal and snacks over the last month. On how many days did you eat fruit foryour morning meal or morning snacks? Count any kind of fruit —fresh, canned, and frozen. Do not count juices.1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day6a. When you ate fruit in the morning, what is the total amount of fruit that you usually ate in a morning?NCI by Meal Screener 17

1 2 3 4 Less than 1 medium fruit 1 medium fruit 2 medium fruits More than 2 medium fruits- OR –1 2 3 4 Less than ½ cup About ½ cup About 1 cup More than 1 cup7. Think about all the foods you ate at your morning meal and morning snacks. On how many days did you eat vegetables for yourmorning meal or morning snacks?DO NOT COUNT: • Lettuce salads• White potatoes• Cooked dried beans• Vegetables in mixtures, such as in sandwiches, omelets, casseroles, Mexican dishes, stews, stir- fry,• RiceCOUNT: • All other vegetables — raw, cooked, canned, and frozen1 2 3 4 5 6 Never1-3 days1-2 days3-4 days5-6 daysEvery(Go to question 8) last monthper weekper weekper weekday7a. When you ate vegetables in the morning, what is the total amount of vegetables that you usuallyate in a morning?1 2 3 4 Less than ½ cup ½ to 1 cup 1 to 2 cups More than 2 cupsNCI by Meal Screener 18

LUNCHTIME AND AFTERNOON8. Think about all the foods you ate at lunchtime and for your afternoon snacks last month. On how many days did you eat fruit atlunchtime or for your afternoon snacks? Count any kind of fruit — fresh, canned, and frozen. Do not count juices.1 2 3 4 5 6 Never1-3 days1-2 days3-4 days5-6 daysEvery(Go to question 8) last monthper weekper weekper weekday8a. When you ate fruit at lunchtime or for your afternoon snacks, what is the total amount of fruit that you usually ate then?1 2 3 4 Less than 1 medium fruit 1 medium fruit 2 medium fruits More than 2 medium fruits- OR -1 2 3 4 Less than ½ cup About ½ cup About 1 cup More than 1 cup9. Think about all the foods you ate at lunchtime and for your afternoon snacks. On how many days did you eat vegetables atlunchtime or for your afternoon snacks?DO NOT COUNT: • Lettuce salads• White potatoes• Cooked dried beans• Vegetables in mixtures, such as in sandwiches, omelets, casseroles,• RiceCOUNT: • All other vegetables —raw, cooked, canned, and frozen1 2 3 4 5 6 Never1-3 days1-2 days3-4 days5-6 daysEvery(Go to question 8) last monthper weekper weekper weekdayNCI by Meal Screener 19

9a.When you ate vegetables at lunchtime or for your afternoon snacks, what is the total amount of vegetables that you usually atethen?1 2 3 4 Less than ½ cup ½ to 1 cup 1 to 2 cups More than 2 cupsSUPPERTIME AND EVENING10. Think about all the foods you ate at suppertime and for your evening snacks last month. On how many days did you eat fruit atsuppertime or for your evening snacks? Count any kind of fruit —fresh, canned, and frozen. Do not count juices.1 2 3 4 5 6 Never1-3 days1-2 days3-4 days5-6 daysEvery(Go to question 8) last monthper weekper weekper weekday10a.When you ate fruit at suppertime or for your evening snacks, what is the total amount of fruit that you usually ate then?1 2 3 4 Less than 1 medium fruit 1 medium fruit 2 medium fruits More than 2 medium fruits- OR –1 2 3 4 Less than ½ cup About ½ cup About 1 cup More than 1 cupNCI by Meal Screener 20

11. Think about all the foods you ate at suppertime and for your evening snacks. On how many days did you eat vegetables atsuppertime or for your evening snacks?DO NOT COUNT: • Lettuce salads• White potatoes• Cooked dried beans• Vegetables in mixtures, such as in sandwiches, omelets, casseroles,• RiceCOUNT: • All other vegetables —raw, cooked, canned, and frozen1 2 3 4 5 6 Never1-3 days1-2 days3-4 days5-6 daysEvery(Go to question 8) last monthper weekper weekper weekday11a. When you ate vegetables at suppertime or for your evening snacks, what is the total amount of vegetables that you usuallyate1 2 3 4 Less than ½ cup ½ to 1 cup 1 to 2 cups More than 2 cupsThese last few questions ask about how often you ate particular foods at any time of the day.12. Over the last month, how often did you eat tomato sauce? Include tomato sauce on pasta or macaroni, rice, pizza and otherdishes.1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper dayNCI by Meal Screener 21

12a. Each time you ate tomato sauce, how much did you usually eat?1 2 3 4 Less than ½ cup About ½ cup About 1 cup More than 1 cup13. Over the last month, how often did you eat vegetable soups? Include tomato soup, gazpacho, and beef with rice?1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper day13a. When you ate vegetable soup, how much did you usually eat?1 2 3 4 Less than 1 cup 1 to 2 cups 2 to 3 cups More than 3 cups14.Over the last month, how often did you eat mixtures that included vegetables? Count such foods as sandwiches, casseroles,stews, stir-fry, omelets, and tacos.1 2 3 4 5 6 7 8 9 10 Never 1-3 timeslast month1-2 timesper week3-4 timesper week5-6 timesper week1 timesper day2 timesper day3 timesper day4 timesper day5 or moretimesper dayNCI by Meal Screener 22

Fruit and Vegetable Module (BRFSS)These questions are about the foods you usually eat or drink. Please tell me howoften you eat or drink each one, for example, twice a week, three times a month,and so forth. Remember, I am only interested in the foods you eat. Include allfoods you eat, both at home and away from home.1. How often do you drink fruit juices such as orange, grapefruit, or tomato?_____ Per day_____ Never_____ Per week_____ Don’t know/Not sure_____ Per month_____ Per year2. Not counting juice, how often do you eat fruit?_____ Per day_____ Never_____ Per week_____ Don’t know/Not sure_____ Per month_____ Per year3. How often do you eat green salad?_____ Per day_____ Per week_____ Per month_____ Per year_____ Never_____ Don’t know/Not sure4. How often do you eat potatoes not including French fries, fried potatoes, orpotato chips?_____ Per day_____ Never_____ Per week_____ Don’t know/Not sure_____ Per month_____ Per year5. How often do you eat carrots?_____ Per day_____ Per week_____ Per month_____ Per year_____ Never_____ Don’t know/Not sure6. Not counting carrots, potatoes, or salad, how many servings of vegetables doyou usually eat? (Example: A serving of vegetables at both lunch and dinnerwould be two servings.)_____ Per day_____ Never_____ Per week_____ Don’t know/Not sure_____ Per month_____ Per yearBRFSS 23

Measures of Consumption for ChildrenTarget behaviorFruit and vegetable consumptionWhat is measured?The following section includes four surveys that measure fruit andvegetable consumption: There are measures for students 3 rd -12 th grades.A 17-item Day in the Life Questionnaire (DILQ) was validated with 7-9year olds. It measures number of times fruits and vegetables were eaten on theprevious day as well as physical activity involvement, TV viewing andtransportation to and from school. The fruit and vegetable consumption portionwas validated by Edmunds, et al. (2002). The other portions of the survey distractfrom the main intent of the survey. Marin Department of Public Health submitteda version of the survey into Spanish, which is also available upon request.Another version of the Day in the Life survey (23-items) was validated byMoore et al. (2007) with low-socioeconomic status children 9-11 years. Itmeasures consumption at home, on the way to school, and at school before thestart of class. While this survey can be used to measure consumption of variousfoods it is included here as a tool to measure fruit and vegetable consumption.Physical activity questions are included to mask the evaluator’s intent to measureconsumption.Both surveys are best administered at the group level by having thesurvey administrator read the questions aloud, prompting children to writeeverything they ate and to be specific about the items eaten. This method willproduce more reliable results than allowing students to complete this withoutassistance and consequently will be more likely to detect a difference if there isone.Both versions of the DILQ are scored the same. To assess consumptionof fruit and vegetables a ‘1’ should be assigned if a fruit, vegetable or 100%juice appears in the answer. A ‘1’ would be recorded even if the answer includesthe number of items eaten or the portion sizes. However, if two or more differenttypes of fruit or vegetables are reported in one time point, each type should bescored as one. For example, if a child writes ‘two apples’, a score of one wouldbe was given to the fruit category for the appropriate time point. If the child hadwritten ‘apple and banana’, a score of two would be recorded in the fruitcategory. All the remaining food and drink should be scored as ‘0’ for the analysisof fruit, vegetable and juice consumption.Three consumption questions were taken from the middle school moduleof the California Health Kids Survey. These are appropriate for 6 th -8 th graders.Measures of Consumption for Children 24

The three consumption questions from the School and Physical ActivityNutrition Project (SPAN) were validated by Hoelscher et al. (2003) with 8 thgraders. Thiagarajah (2006) reported moderate to good reliability with 4 thgraders. These questions are suitable for 4 th and 5 th graders.The Youth Risk Behavior Survey (YRBS) has a six question fruit andvegetable component. Participants report the number of times in the past sevendays that they consumed fruit, juices, vegetables, salads, potatoes, and carrots.Data should be analyzed to approximate the number of times per day that theparticipant ate fruits and vegetables.The Food Recognition Form (Cullen et al. 2003) is a modified recall of thefoods that were eaten at breakfast, lunch, dinner, and during snacks on theprevious day. Participants are given a list of food items and can check them ifthey ate them for meals or snacks.The last survey, validated by Nanney et al., is a 28-item food frequencyquestionnaire. It was developed to be administered by an interviewer to a parentto capture the number of times they and their child ate fruits and vegetables overthe past week.Who is the target audience?DILQ 7-9 years: 3 rd and 4 th gradersDILQ 9-11 years 4 th and 5 th gradersCHKS 6 th – 8 th gradesYRBS: Teenagers in grades 9-12, roughly between the ages of 14 and 18Food Recognition Form: Girls 9-12 yearsFood Frequency Questionnaire – children 7-9 via parent reportsAdditional informationNone of these should be modified. Choose a survey with questions thatmost closely match your intervention goals and one in which participants arelikely to report eating more fruits and vegetables after the intervention than theydid before.ReferencesEdmunds LD, Ziebland S. Development and validation of the Day in the LifeQuestionnaire (DILQ) as a measure of fruit and vegetable questionnairefor 7-9 year olds. Health Educ Res. 2002 Apr;17(2):211-20.Moore GF, Tapper K, Murphy S, Clark R, Lynch R, Moore L. (2007) Validation ofself-completion measure of breakfast foods, snacks, and fruits andvegetables consumed by 9-11 year old school children. European Journalof Clinical Nutrition, 61, 420-430.Cullen K, Bartholomew L. Validity of a 1-day food recognition form to measurefruit and vegetable consumption in 9-12 year old girls. PosterMeasures of Consumption for Children 25

Presentation: American Dietetic Association Food and NutritionConference and Expo. 2003.Youth Risk Behavior Surveillance System. 2005 State and Local Standard HighSchool Questionnaire.http://www.cdc.gov/nccdphp/dash/yrbs/2003/questionnaire.htmNanney MS, Haire-Joshu D, Elliot M, Hessler K, Brownson RC. (2005)Evaluating changeability to improve fruit and vegetable intake amongschool aged children. Nutrition Journal 4, 34.Measures of Consumption for Children 26

The Day in the Life Questionnaire (7-9 years)DILQ for 7-9 years 27

DILQ for 7-9 years 28

DILQ for 7-9 years 29

DILQ for 7-9 years 30

Day in the Life Questionnaire (9-11 years)DILQ 9-11 years 31

This is a form about what you did this morning and yesterday. There are23 questions. It is not a test so there are no right or wrong answers. Theimportant thing is that you answer the questions truthfully and try yourhardest to remember what you did and what you had to eat and drink.Here is an example:2. Did you have anything to eat ordrink at home this morning?NoYesWhat did you have to eat or drink?.........................................................................................................................................................................................Write downEVERYTHINGyou canremember!3. How did you travel to school this morning?If you didn’t have anything to eat or drink at home this morning, youshould put a tick in the box that says ‘No’. You should then follow thearrow to the next question.If you did have something to eat or drink at home this morning you shouldput a tick in the box that says ‘Yes’. You should then follow the arrow tothe box with the blank lines and write down everything you had to eat anddrink. It is important that you try hard to remember exactly what youhad to eat and drink and that you write down everything. Once you aresure that you have remembered everything you should follow the arrow tothe next question.All your answers are a secret between you and the people helping you fillout the form. Nobody else will see your answers. Please don’t talk toanyone else while you are filling in the form and try not to let anyone elsesee what you put down.If there is anything you don’t understand or any words that you are notsure about then make sure you ask. There is no rush so you can take aslong as you like.DILQ 9-11 years 32

What did you do this morning?1. Did you watch television at home this morning?NoYes(Put a tick in the correct box)2. Did you have anything to eat ordrink at home this morning?NoYesWhat did you have to eat or....................................................................................................................................................Write downEVERYTHINGyou canremember!3. How did you travel to school this morning?walk cycle by bus by carDILQ 9-11 years 33

4. Did you have anything to eat ordrink on the way to school thismorning?NoYesWhat did you have to eat or........................................................................................................................................................Anythingelse?5. Did you have anything to eat ordrink at school this morning,before class started?If so,WRITEITNoTurn over!YesWhat did you have to eat ordrink?........................................................................................................................................................Write downEVERYTHINGyou canDILQ 9-11 years 34

What did you do yesterday?6. Did you watch television at home yesterday morning?NoYes(Put a check in the correct box)7. Did you have anything to eat ordrink at home yesterday morning?NoYesWhat did you have to eat or....................................................................................................................................................Have you writtendownEVERYTHING?8. How did you travel to school yesterday morning?walk cycle by bus by carDILQ 9-11 years 35

9. Did you have anything to eat ordrink on the way to schoolyesterday morning?NoYesWhat did you have to eat or........................................................................................................................................................10. Did you have anything to eat ordrink at school yesterday morning,before class started?Have yourememberedeverything?NoYesWhat did you have to eat or........................................................................................................................................................Have youwritten downEVERYTHING?11. What did you do at morning break (interval) yesterday?sat around stood around walked around ran aroundDILQ 9-11 years 36

12. Did you have anything to eat ordrink at morning break yesterday?NoYesWhat did you have to eat or drink?...............................................................................................................Have youforgottenanything?13. What did you do at lunchtime yesterday?sat around stood walked ran around14. Did you have anything to eat ordrink at lunchtime yesterday?NoTurn over!YesWhat did you have to eat or drink?....................................................................................................................................................Anythingelse?If so,WRITEITDILQ 9-11 years 37

15. What did you do after school yesterday?went homewent to an afterschool clubwentsomewhere else16. How did you travel home after school yesterday?walk cycle by bus by car17. Did you play outside after school yesterday?NoYes18. Did you watch television after school yesterday?NoYesDILQ 9-11 years 38

19. Did you have anything to eat or drink on yourway home yesterday? Or anything to eat or drinkbetween the end of school and your evening meal?NoYesWhat did you have to eat ordrink?..................................................................................................................Have yourememberedeverything?20. Did you have an evening meal yesterday?NoYesWhat did you have to eat or........................................................................................................................................................Have youwritten downE E21. What did you do after your evening meal yesterday? (If you didn’thave an evening meal, write down what you did before you went to bed.)................................................................................................................................................................DILQ 9-11 years 39

22. Did you have anything else to eat or drink after yourevening meal yesterday or before you went to bed?NoYesWhat did you have to eat or....................................................................................................................................................Anythingelse?23. Did you have anything else to eat or drinkyesterday that you haven’t already put on this form?NoYesWhat did you have to eat ordrink?.........................................................................................................................................................................................Anythingelse?If so,WRITEITDILQ 9-11 years 40

California Healthy Kids Survey (CHKS)During the past 24 hours (yesterday), how many times did you…(please circle the number of times)Drink 100% fruit juices, such as orange,apple or grape?0 1 2 3 4Eat fruit? (Do not count fruit juice.) 0 1 2 3 4Eat vegetables? (Include salads and non-friedpotatoes.)0 1 2 3 45 ormore5 ormore5 ormoreYRBS 41

School Physical Activity and Nutrition Project(SPAN)1. Yesterday, did you eat any vegetables?Vegetables are all cooked and uncooked vegetables; salads; and boiled,baked and mashed potatoes.Do not count French fries or chips.O No, I didn’t eat any vegetables yesterday.O Yes, I ate vegetables 1 time yesterday.O Yes, I ate vegetables 2 times yesterday.O Yes, I ate vegetables 3 or more times yesterday.2. Yesterday, did you eat fruit?Do not count fruit juice.O No, I didn’t eat any fruit yesterday.O Yes, I ate fruit 1 time yesterday.O Yes, I ate fruit 2 times yesterday.O Yes, I ate fruit 3 or more times yesterday.3. Yesterday, did you drink fruit juice?Fruit juice is a 100% juice drink like orange juice, apple juice, or grapejuice.Do not count punch, Kool-Aid®, sports drinks and other fruitflavoreddrinks.O No, I didn’t drink any fruit juice yesterday.O Yes, I drank fruit juice 1 time yesterday.O Yes, I drank fruit juice 2 times yesterday.O Yes, I drank fruit juice 3 or more times yesterday.YRBS 42

Youth Risk Behavior Survey (YRBS)Fruit and Vegetable Questions1.2.3.4.YRBS 43

5.6.YRBS 44

Food Recognition Form (Cullen, et al.)Directions: Mark each food you ate at lunch, supper and snacks for the last 24hours.LUNCH SUPPER SNACKS Buy TakeProtein FoodsBeef, Pork, Ham Chicken, Fish Pizza Lasagna Spaghetti and Meat sauce Tacos, Enchiladas Tuna fish, Cheese, Egg Hamburger, Hot dog Peanut butter sandwich Lunch meat, bologna Beans, black-eyed peas Other_____________ Breads & GrainsNoodles, macaroni, rice Biscuits, cornbread Bread, buns Tortillas VegetablesCorn Mixed Vegetables Green Beans Broccoli Peas Carrots Tomatoes Celery Lettuce, tossed salad Squash, Zucchini French fries, tater tots Potatoes: mashed, baked Spinach Other_____________ Food Recognition Form 45

FruitsChipsApples, applesauce Bananas Berries or cherries Grapes Oranges or grapefruit Peaches Melon Pears Kiwifruit, mango Raisins Other_____________ Potato Chips, corn chips Nachos, Nuts Pretzels, Popcorn, CrackersOther_____________ Sweets & DessertsCookies, Granola Bar Cake, cupcakes, pie Donuts, sweet rolls Candy (pieces, bar) Pudding, jello Ice cream, popsicle Other____________ DrinksMilk, low-fat white or chocolateMilk, regular white or chocolateIced tea Soft drink Fruit drink, Kool-aid, drink box Fruit juice___________ Coffee Water Hot Chocolate Other_____________ Food Recognition Form 46

OtherButter Margarine Jam or Jelly Sugar Salad Dressing CerealsBreadsDrinksOrange juiceApple juiceOther juiceMilk, low fatMilk, regularCoffee, TeaOther_____________Hot cereal (oatmeal,grits)Coldcereal____________Toast or breadBiscuitsMuffinsDonuts, sweet rollsPop tartsFrench toastPancakesWafflesBREAKFASTProtein FoodsEggsSausageBaconCheesePeanut butterOther_____________Food Recognition Form 47

Development of the SLU 4 Kids FFQ was done by researchers at Saint Louis University School of Public Health.This work was funded by NIH/NCI with Debra Haire-Joshu as the Principal Investigator.Food Frequency Questionnaire[This survey should be administered to a parent or guardian of the child participatingin the evaluation. If more than one parent or guardian is available choose the onewho knows the most about the child’s consumption]1. Before we begin, how many of the last seven days was (child’s name) with you?INTERVIEWER, PLEASE SILENT CODE. THIS RESPONSE CAN BE A DECIMALSUCH AS .5 FOR A HALF DAY.(0,7 hard range)---------INTERVIEWER, DON’T READ--------- Don’t know/not sure RefusedThe first set of questions for this interview are about the foods and drinks that you and (child’s name)have had both at home and away from home for the past seven days. As you answer the questions,please keep in mind that there are no right or wrong answers. We know that we all sometimes haveodd eating habits. You should feel comfortable answering as honestly as you can because youridentity will not be connected to your responses. Do you have any questions before we begin?2. In the last week, was (child’s name)’s eating habits typical of the way (child’s name) usuallyeats? No Yes---------INTERVIEWER, DON’T READ--------- Don’t know/not sure Refused3. In the last week, were your eating habits typical of the way you usually eat? No Yes---------INTERVIEWER, DON’T READ--------- Don’t know/not sure RefusedFor the majority of this section, I am going to ask you to think about every time (child’s name) and youate or drank in the last seven days. First, I will ask how much (child’s name) likes that food. You canchoose that the food is your child’s favorite, that (child’s name) likes it, that (child’s name) doesn’t likeit, that (child’s name) hate its, or that (child’s name) has never had it. Next, I will ask if (child’s name)has had that particular food or drink in the last seven days. If (child’s name) did, I will ask you howmany times. You can answer one time, two times, three to four times, five to six times or seven ormore times. Finally, I will ask the same questions about you. Remember to include all food and drinksthat you and (child’s name) ate and drank. Include food and drinks at school, work, at other people’shomes, at restaurants and from vending machines.Food Frequency Questionnaire 48

4. Apples?Includeapplesauce.5. 100%applejuice?First, I will ask you about the fruits that you and (child’s name) have had to eat in the past seven days. Remember to include all fresh,frozen and canned fruits that were eaten at home and away from home in past seven days.“What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these column]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 49

6. 100%Orangejuice? NotSunnyDelight. Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Don’tknow/NotSure RefusedNOYES123-45-67+Don’tknow/NotSureDon’tknow/NotSureNOYES123-45-67+Don’tknow/ NotSureFood Frequency Questionnaire 50

7. Other100%juice?Include100% grapejuice. NotFruitopia.8.Oranges?“What is (yourchild’s name)preference for…”Do not askpreference. Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 51

9.Bananas? Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Don’tknow/NotSure RefusedNOYES123-45-67+Don’tknow/NotSureDon’tknow/NotSureNOYES123-45-67+Don’tknow/ NotSureFood Frequency Questionnaire 52

10.Grapes?“What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused 11. Pears? Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 53

12. Favorite Cantaloupe Likes it ? Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Don’tknow/NotSure RefusedNOYES123-45-67+Don’tknow/NotSureDon’tknow/NotSureNOYES123-45-67+Don’tknow/ NotSureFood Frequency Questionnaire 54

13.Strawberries?14.Pineapple?“What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 55

15. FruitCocktail?16.Peaches?17. Otherfruit notalreadymentioned? Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused “What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Do not askpreference.Don’tknow/NotSure RefusedNOYES123-4[Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES5-67+Don’tknow/NotSure[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureNOYES123-45-67+[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYESDon’tknow/ NotSure[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 56

18. Baked,mashed orboiledpotatoes?Not fried.Now, I will ask you about the vegetables that you and (child’s name) have had to eat in the past seven days. Rememberto include all fresh, frozen and canned vegetables that were eaten at home and away from home in past seven days.[Record answers for child in these columns][Record answers for parent in these columns]“What is (your “In the last seven[IF YES]“In the last sevenchild’s name) days, did (child’sdays, did youpreference for name) have…” “How many times?” have…”…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused “What is (yourchild’s name)preference for…”Don’tknow/NotSure RefusedNOYES123-4[Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”5-67+Don’tknow/NotSure[IF YES]“How many times?”Don’tknow/NotSureNOYES[IF YES]“How many times?”123-45-67+[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/ NotSure[IF YES]“How many times?”Food Frequency Questionnaire 57

19. Friedpotatoes?IncludeFrenchfries andhashbrowns.20.Lettuce?Include onsandwiches or salads.21.Spaghettior pizzasauce? Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONONOYESYESYES1112223-43-43-45-65-65-67+7+7+Don’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureNONONOYESYESYES1112223-43-43-45-65-65-67+7+7+Don’tknow/ NotSureDon’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 58

Food Frequency Questionnaire 59

22.Tomatoes?Includethose onsandwiches, in soupand insalsa.23. Greenbeans?“What is (yourchild’s name)preference for …” Favorite Likes it Doesn’t like it Hates it 5 Has never had itskip to parent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t like it Hates it 5 Has never had itskip to parent----Don’t Read----- Don’t know/Not Sure Refused 24. Corn? Favorite Likes it Doesn’t like it Hates it 5 Has never had itskip to parent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/ NotSureRefusedDon’tknow/ NotSureRefusedDon’tknow/ NotSureRefusedNONONOYESYESYES[IF YES]“How many times?”1112223-43-43-45-65-65-67+7+7+Don’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureNONONOYESYESYES[IF YES]“How many times?”1112223-43-43-45-65-65-67+7+7+Don’tknow/ NotSureDon’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 60

25. GreenPeas?26.Broccoli?“What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused [Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSure[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureDon’tknow/NotSureNONOYESYES[IF YES]“How many times?”11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSureFood Frequency Questionnaire 61

27.Carrots?28. Mixedvegetables? Includingthose insoups. Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused “What is (yourchild’s name)preference for…” Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Don’tknow/NotSure RefusedNOYES123-4[Record answers for child in these columns]“In the last sevendays, did (child’sname) have…”Don’tknow/NotSure RefusedNOYES5-67+Don’tknow/NotSure[IF YES]“How many times?”123-45-67+Don’tknow/NotSureDon’tknow/NotSureNOYES123-45-67+[Record answers for parent in these columns]“In the last sevendays, did youhave…”Don’tknow/NotSureNOYESDon’tknow/ NotSure[IF YES]“How many times?”123-45-67+Don’tknow/ NotSureFood Frequency Questionnaire 62

29. Beans?like bakedor refriedbeans andbeandishes.30. Othervegetablesnot alreadymentioned? Favorite Likes it Doesn’t likeit Hates it 5 Has never hadit skip toparent----Don’t Read----- Don’t know/Not Sure Refused Do not askpreference.Don’tknow/NotSure RefusedDon’tknow/NotSure RefusedNONOYESYES11223-43-45-65-67+7+Don’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureDon’tknow/NotSureNONOYESYES11223-43-45-65-67+7+Don’tknow/ NotSureDon’tknow/ NotSure31. Does (child’s name) usually take a multivitamin or mineral supplement? No Yes---------INTERVIEWER, DON’T READ--------- Don’t know/not sure RefusedFood Frequency Questionnaire 63

Availability SurveysTarget behaviorIncreasing fruit and vegetable consumptionWhat is being measured?Availability of fruits and vegetables is one factor known to influence fruitand vegetable intake (Cullen, et al., 2003). The first survey measures availabilityof fruits, juices, and vegetables at school. The second and third measureavailability of these items at home.Who is the target audience?Adults: The first survey that measures availability of fruits and vegetablesat school is for adult school staff. The second survey measures availability offruits and vegetables at home and has been validated with parents of 4 th -6 thgrade students. The third survey is suitable for students in grades 4 and above.Additional informationThe survey by the Network for a Healthy California has not been validatedand may be modified.The validity of the first instrument by Hearn, et al. (1998) was assessed bycomparing interviewer observed shelf inventories with shelf inventories reportedby parents of 4 th – 6 th graders. The Cohen kappa was statistically significant(p

Availability Survey – Fruit, Juice & Vegetables atSchool (Network)Are the following fruits available in the school?If ‘Yes’, check the appropriate box(es) to indicate where or when.SchoolBreakfastPlease check all that applyAfterSchool School A LaLunch Snack CarteProgramVendingApples Apple Juice Bananas Strawberries Fruit juice Applesauce Peaches Are the following vegetables available in the school?If ‘Yes’, check the appropriate box(es) to indicate where or when.Please check all that applySchoolBreakfastSchoolLunchAfterSchoolProgramA LaCarteVendingCarrots 1 2 3 4 5 Corn 1 2 3 4 5 Potatoes (not fried) 1 2 3 4 5 Green Salad 1 2 3 4 5 Green beans 1 2 3 4 5 Broccoli 1 2 3 4 5 Peas 1 2 3 4 5 Tomatoes 1 2 3 4 5 Availability 65

Availability Survey – Fruit, Juice & Vegetables AtHome (Hearn, et al.)Did you have any of the following fruits or vegetables in yourhome during the past week? It may have been fresh, frozen,canned, or dried.Please check all that applyYesNoApples Apple Juice Bananas Greens Potatoes (not French fries) Tomatoes Did you have any 100% fruit juice in your home during the pastweek? It may have been fresh, frozen, canned, or dried.Please check all that applyYesNo100% Apple 100% Grape 100% Orange Availability Survey (Hearn)These two questions will help explain why you may or may not eat fruitsand vegetables. Please fill in one answer for each question.1. At your home do you have fruits to eat?O NeverO SometimesO AlwaysO I don’t know2. At your home do you have vegetables to eat?O NeverO SometimesO AlwaysO I don’t knowAvailability 66

School and Idea Resource KitTarget behaviorFruit and vegetable consumption and physical activityWhat is being measured?This survey includes scales that measure: children's knowledge about fruit and vegetables positive outcome expectations for eating fruit and vegetables self-efficacy in asking, and shopping for fruit and vegetables self-efficacy for eating fruit and vegetables children’s knowledge about physical activity outcome expectations for the physical outcomes of engaging inphysical activity self-efficacy for engaging in physical activity recall of the Power Play! CampaignWho is the target audience?Children ages 9 to 11Additional informationThe Network for a Healthy California developed this survey to evaluate theimpact of the Power Play! Campaign’s School Idea and Resource Kit (SIRK).The SIRK is one element, classroom-based nutrition education, of a multilevelstatewide social marketing campaign that encourages low-income, 9- to 11-yearoldchildren and their families to eat the recommended amount of fruits andvegetables and be active for at least 60 minutes every day.This survey was developed using measures from existing literature. Areview of the literature produced a short list of valid and reliable measures for 9-to 11-year-old children. These measures were reviewed to determine whichscales best fit the fruit and vegetable and physical activity determinants mostfrequently addressed in the SIRK. The knowledge questions were developeddirectly from the content of the SIRK activities. The psychosocial measuresselected were fruit and vegetable and physical activity self-efficacy and outcomeexpectations. After selecting the scales, the instrument was pilot tested with thetarget audience, reduced in length, and finalized. The length of the survey waslimited in size and scope to keep children actively engaged. The final instrumentwas designed to be easily conducted by teachers with brief written instructionson survey administration.Positive fruit and vegetable outcome expectations (9 items) measuredresponses on a 5-point Likert scale ranging from 1 (disagree very much) to 5PowerPlay! 67

(agree very much). Fruit and vegetable self-efficacy was drawn from a 22-question instrument provided by Baranowski and colleagues (2004). Afterdeleting items with no relevance to the intervention, the asking and shoppingself-efficacy measure equaled 8 items, and eating self-efficacy was reduced to 3questions. Both scales used the same 5 response options outlined above. Thephysical activity outcome expectations were measured by 7 items. The originalscale was reduced by three questions with a factor loading

ReferencesBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L,Wang DT. Gimme 5 fruit and vegetables for fun and health: OutcomeEvaluation. Health Education & Behavior 2000; 27(1):96-111.Network for a Healthy California. (2005) Five a Day Power Play! Pre-Post ImpactSurvey. Unpublished.Saunders R P, Pate R, Felton G, Dowda M, Weinrich M, Ward D, Parsons M, &Baranowski T. Development of questionnaires to measure psychosocialinfluences on children's physical activity. Preventive Med 1997; 26, 241-247.5 a Day PowerPlay! 69

PRE/POST IMPACT SURVEYWe want to know what you think about fruits and vegetables. There are no rightor wrong answers, just your opinion. Please circle the answer that bestdescribes what you think.FRUITS AND VEGETABLESPlease choose your answer.False True1. Eating fruits and vegetables protects you fromdiseases. F T2. Most of the vitamin C we get comes from fruitsand vegetables. F T3. How many servings of fruits and vegetables do you think elementaryschool students should eat each day to be healthy?A. 1 servingB. 2 servingsC. 3 servingsD. 4 servingsE. 5 or more servingsF. Don’t know4. How many servings of vegetables do kids your age need every day?A. 1 servingB. 2 servingsC. 3 servingsD. 4 servingsE. 5 servings70

We want to know what you think will happen if you eat fruits and vegetables everyday. There are no right or wrong answers, just your opinion. Please circle theanswer that best describes how much you disagree or agree with each sentencebelow.FRUITS AND VEGETABLES(IF I EAT)If I eat fruits and vegetables every day…I disagreeverymuchPlease choose your answer.Idisagreea littleI amnotsureI agreea little5. I will become stronger A B C D EI agreeverymuch6. my friends will start eating them too A B C D E7. I will have stronger eyes A B C D E8. I will have a nicer smile A B C D E9. I will be healthier A B C D E10. I will think better in class A B C D E11. it will keep me from getting fat A B C D E12. I will have more energy A B C D E13. my family will be proud of me A B C D EWe want to know how sure you are that you can do things to eat more fruits andvegetables. There are no right or wrong answers, just your opinion. Please circlethe answer that best describes how much you disagree or agree with eachsentence below.FRUITS AND VEGETABLES (I THINK)Please choose your answer.I disagreeverymuchI disagreea littleI am notsureI agreea littleI agreeverymuch14. I think I can write my favorite fruit orvegetable on the family’s shopping list15. I think I can ask someone in my familyto buy my favorite fruit or vegetable16. I think I can go shopping with my familyfor my favorite fruit or vegetable17. I think I can pick out my favorite fruit orvegetable at the store and put it in theshopping basketA B C D EA B C D EA B C D EA B C D E71

FRUITS AND VEGETABLES (I THINK)18. I think I can ask someone in my familyto make my favorite vegetable dish fordinner19. I think I can ask someone in my familyto serve my favorite fruit at dinner20. I think I can ask someone in my familyto have fruits and fruit juices out whereI can reach them21. I think I can ask someone in my familyto have cut up vegetables out whereI can reach them22. I think I can eat 2 or more servings offruit or fruit juice each day23. I think I can eat 3 or more servings ofvegetables each day24. I think I can eat 5 or more servings offruits and vegetables each dayI disagreeverymuchPlease choose your answer.I disagreea littleI am notsureI agreea littleI agreeverymuchA B C D EA B C D EA B C D EA B C D EA B C D EA B C D EA B C D E72

We want to know what you think about physical activity. Remember that physicalactivity can be any play, game, sport, or exercise that gets you moving andbreathing harder. There are no right or wrong answers, just your opinion. Pleasecircle the answer that best describes what you think.PHYSICAL ACTIVITYPlease choose your answer.25. How many minutes of physical activity do you think elementary schoolstudents should get each day to be healthy?A. At least 15 minutes each dayB. At least 30 minutes each dayC. At least 60 minutes each dayD. At least 90 minutes each dayE. Don’t know26. Why is physical activity good for kids?A. Helps keep you from getting sickB. Helps you pay attention in schoolC. Builds healthy bones and muscles to keep you strongD. Gives you more energyE. All of the above73

Please circle either “No” or “Yes” for each of the sentences below. “No” meansthat you do not agree with the sentence. “Yes” means that you agree with thesentence. Remember that physical activity can be any play, game, sport, orexercise that gets you moving and breathing harder.PHYSICAL ACTIVITY (I THINK)Please choose your answer.27. I think I can be physically active most days after school N Y28. I think I can ask my parent or other adult to do physicallyactive things with meN Y29. I think I can ask my parent or other adult to sign me upfor a sport, dance, or other physical activityN Y30. I think I can be physically active even if it is very hot orcold outsideN Y31. I think I can ask my best friend to be physically activewith meN Y32. I think I can ask my parent or other adult to get me theequipment I need to be physically activeN Y33. I think I can ask my parent or other adult to take me to aphysical activity or sport practiceN Y34. I think I can be physically active even if I have a lot ofhomeworkN Y35. I think I have the skills I need to be physically active N Y36. I think I can be physically active no matter how busy myday isN Y37. I think I can be physically active no matter how tired Imay feelN YNoYesPHYSICAL ACTIVITY (IT WOULD)Please choose your answer.If I were to be physically active most days… No Yes38. it would help me be healthy N Y39. it would help me control my weight N Y40. it would make me embarrassed in front of others N Y41. it would be fun N Y42. it would get or keep me in shape N Y43. it would be boring N Y44. it would make me better in sports N Y74

We want to know what you think about 5 a Day—Power Play! There are no right orwrong answers, just your opinion. Please circle the answer that best describes whatyou think.POWER PLAY45. Have you heard of the 5 a Day—Power Play! Campaign?A. YesB. NoC. Don’t knowPlease choose your answer.46. What does 5 a Day—Power Play! mean? Please circle only one answer.A. Five food groupsB. Exercise five times every dayC. Eat 5 servings of fruits and vegetables and get 60 minutes of physicalactivity every day for good healthD. Drink five sodas each day for energyE. Don’t knowSchool Idea and Resource Kit Impact Survey 75

Harvest of the Month SurveyTarget behaviorFruit and vegetable consumptionWhat is being measured?The HOTM survey was developed using questions from various sources. Theitems were compiled to measure change in fruit and vegetable consumption and threefactors that influence it. These factors included knowledge, food preferences, and selfefficacy.Questions one through five measure knowledge. They were developed by agroup of Network funded contractors from Orange County, CA that reviewed the HOTMmaterials and identified the essential pieces of knowledge that they felt students shouldgain after participating in the intervention. These questions were reviewed by theResearch and Evaluation Unit of the Network for a Healthy California of the CA Dept ofHealth Services.Question six measures food preferences. These questions were adapted from asurvey developed by Cullen, et al. The Network’s contractors may modify the list of fruitand vegetables so it includes the items they feature when implementing theintervention. The list may include more fruit and vegetables than those featured inHOTM.Questions 7-11 measure self-efficacy for eating. They were developed byBaranowski, et al. 1 to assess a child’s confidence that they can eat fruit and vegetablesat breakfast, lunch, for snacks and at dinner.Questions 12-14 provide a measure of consumption. They were taken from theCalifornia Healthy Kids Survey Middle School Questionnaire, Module A, Core,Questions A15, A17, and A18.Who is the target audience?Children in 4 th and 5 th gradesAdditional informationHarvest of the Month (HOTM) is an intervention designed to increase fruit andvegetable consumption among low-income populations. It was developed by theNetwork for a Healthy California (Network) for agencies contracted to promote fruit andvegetable consumption throughout the state.For knowledge, the correct answers should be added to get a summary score,which will range between 0 and 5. The correct answers are marked with a “1”.There are several ways to analyze change in the summary scores forpreferences. The Network conducts two methods and only includes items featured inthe intervention. The first answers the question: Did respondents become familiar with1 Baranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L, WangDT. Gimme 5 fruit and vegetables for fun and health: Outcome Evaluation. Health Education &Behavior 2000; 27(1):96-111.Harvest of the Month Survey 76

fruits or vegetables that were previously unknown to them? This analysis would capturechange in the proportion of respondents who move from “I don’t know what this is” to “Idon’t like it”, “I like it a little” or “I like it a lot”. A McNemar test is appropriate for thisanalysis.The second question is: Did preferences change for those who knew what theitem was? This analysis excludes those individuals who reported, at pretest, notknowing what the item was. The rationale is that those who cannot identify an item donot have a preference for it. A paired t-test is used to capture movement within the threepreference responses.For self-efficacy, conduct a paired-t-test on summary scores for the subscalesand all scales together. The results for consumption, expressed as number of times,should be reported separately for each question and for all questions combined.ReferencesCullen K, Baranowski T, et al. Availability, accessibility, and preferences for fruit, 100%fruit juice, and vegetables influence children's dietary behavior. Health EducBehav 2003; 30(5): 615-26.Baranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L, Wang DT.Gimme 5 fruit and vegetables for fun and health: Outcome Evaluation. HealthEducation & Behavior 2000; 27(1):96-111.Harvest of the Month Survey 77

Harvest of the Month SurveyPrepared bythe Research and Evaluation Unitof the Network for a Healthy CaliforniaConfidentiality information to be explained to studentsWe would like for you to complete this survey. You may skip questions you do not want toanswer but we hope that you will answer all of them. Any information about who you arewill be kept secret. We will not share your name or identification number. They will onlybe used for reports.HOTM 78

Student identification number______________________________We want you to tell us what you know about healthful eating.Please bubble your answer 1. Eating fruits and vegetables can help lower your chances of getting heart diseaseor cancer.O TrueO FalseO Don’t know2. Fruits and vegetables that are high in Vitamin A are ____________ in color.O Red and whiteO Blue and light brownO Yellow-orange and dark greenO Brown and purpleO I don’t know3. Almost all fruits and vegetables contain a lot of vitamins and _______________.O ProteinO FiberO CholesterolO FatO Don’t know4. Which of the following fruits and vegetables are grown in California:O SpinachO ApplesO PearsO All of the above5. Fruits and vegetables, like apples and pears, are best when eaten with the peelbecause that is where most of the fiber and antioxidants are.O TrueO FalseO Don’t knowHOTM 79

6. How much do you like these fruits and vegetables? Please bubble your answerI like this a lotI like this a little I do not like this I don’t know whatthis isAsparagus……………. O O O OAvocados…………….. O O O OBeets…………………. O O O OBroccoli………………. O O O OCabbage……………… O O O OCooked Greens……… O O O OCorn…………………. O O O ODried Plum…………… O O O OGrapefruit…………… O O O OGreen Beans………… O O O OMandarins(Tangerines)O O O OMelons………………. O O O OMushrooms………… O O O ONectarines…………… O O O OOnions………………… O O O OPersimmons………… O O O OPlums…………………. O O O ORadishes……………… O O O OSalad Greens………… O O O OSpinach……………… O O O OSweet Potatoes……… O O O OTomatoes…………… O O O OAre there other fruits that you really like? □ Yes → what kind?________________________Are there other vegetables that you really like? □ Yes → what kind?_____________________HOTM 80

7. For breakfast, I think I can…I disagreevery muchPlease bubble your answer I disagreea littleI am notsureI agree alittleI agreevery muchA. drink a glass of my favorite juice O O O O OB. add fruit to my cereal O O O O O8. For lunch at school, I think I can…I disagreevery muchI disagreea littleI am notsureI agree alittleI agreevery muchA. eat a vegetable that’s served O O O O OB. eat a fruit that’s served O O O O O9. For lunch at home I think I can…I disagreevery muchI disagreea littleI am notsureI agree alittleI agreevery muchA. eat carrot or celery sticks insteadof chipsB. eat my favorite fruit instead of myusual dessert10. For a snack I think I can choose…A. my favorite fruit instead of myfavorite cookieB. my favorite fruit instead of myfavorite candy barC. my favorite raw vegetable insteadof my favorite cookieD. my favorite raw vegetable insteadof my favorite candy barE. my favorite raw vegetable insteadof chipsO O O O OO O O O OI disagreevery muchI disagreea littleI am notsureI agree alittleI agreevery muchO O O O OO O O O OO O O O OO O O O OO O O O OHOTM 81

11. For dinner I think I can….I disagreevery muchI disagreea littleI am notsureI agree alittleI agree verymuchA. eat a serving of vegetables O O O O OB. eat my favorite fruit instead of myusual dessertO O O O ODuring the past 24 hours (yesterday), how many times did you…(please circle the number of times)12. Drink 100% fruit juices, such as orange,apple or grape?0 1 2 3 413. Eat fruit? (Do not count fruit juice.) 0 1 2 3 414. Eat vegetables? (Include salads and nonfriedpotatoes.)0 1 2 3 45 ormore5 ormore5 ormore15. How old are you?Years16. Are you O BoyO Girl17. Are you Hispanic or Latino?O YesO No18. What is your race? (Select one or more responses.)O American Indian or Alaska NativeO AsianO Black or African AmericanO Native Hawaiian or Other Pacific IslanderO WhiteHOTM 82

Network Youth Survey and Network High SchoolSurveysBackgroundTarget behaviorHealthy and unhealthy food consumption including fruits and vegetablesWhat is being measured?The focus of the impact evaluation tool was expanded in October 2009 toinclude more than fruit and vegetables outcomes because Network contractorsfocus on topics related to healthy and unhealthy foods covered in MyPyramidand the Dietary Guidelines and similar resources. The first set of questions below(3, 4, 5, 7, 8, 10) measure consumption of healthy foods including milk, fruit andvegetables and breakfast. The questions about cereal and breakfast (question15) were included because eating breakfast cereal and eating breakfast areassociated with reduced risk of obesity among children. Many educators whoteach about healthy foods also include activities to discourage consumption ofunhealthy foods such as those in the second set of questions (6, 9, 11, 12).Question 13 and 14 assess change in physical activity. Measures of perceivedpeer behavior and access were included as outcome measures. Poor outcomesin these areas would signal a need for strengthened parent education. Thesequestions would also to help explain change in fruit and vegetable consumption.For example, students who don’t have access and don’t perceive their parentseating fruit and vegetables would be less likely to change fruit and vegetableconsumption than those who do have access and see their parents eating fruitand vegetables.Healthy Foods (5 questions) 1,2,33. Yesterday, did you drink any kind of milk?4. Yesterday, did you eat yogurt or cottage cheese or string cheese ordrink a yogurt drink?5. Yesterday, did you eat any hot or cold cereal?7. Yesterday, did you eat any vegetables?8. Yesterday, did you eat fruit?10. Yesterday, did you drink fruit juice? Fruit juice is a drink, which is100% juice, like orange juice, apple juice, or grape juice.Unhealthy Foods (4 questions) 1,2,36. Yesterday, did you eat French fries or chips?9. Yesterday, did you drink any punch, sports drinks or other fruit-flavoreddrinks?11. Yesterday, did you drink any regular (not diet) sodas or soft drinks?Network Youth Survey 83

12. Yesterday, did you eat sweet rolls, doughnuts, cookies, brownies,pies, or cake?Physical Activity (2 questions) 1,2,313. Below, check the days you exercised or took part in physical activitythat made your heart beat fast and made you breathe hard for at least60 minutes?14. Below, check the days you play outdoors for at least 30 minutes?Other (2 questions)15. Yesterday, did you eat breakfast?16. I like to try new foods.Perceived Parental Consumption (2 questions) 417. How often do your parents eat fruit?18. How often do your parents eat vegetables?Access (2 questions) 519. At your home do you have fruits to eat?20. At your home do you have vegetables to eat?The Network High School Survey includes the same question as the youthsurvey except the ones about fruit and vegetable consumption. These werereplaced with six questions from the YRBS. These include the following. Theresponse categories range from 0 days to 4 or more times a day.YRBS fruit and vegetable consumption questions on Network High SchoolSurvey7. During the past 7 days, how many times did you drink 100% fruit juices suchas orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid,sports drinks, or other fruit-flavored drinks.)8. During the past 7 days, how many times did you eat fruit? (Do not count fruitjuice.)9. During the past 7 days, how many times did you eat green salad?10. During the past 7 days, how many times did you eat potatoes? (Do notcount french fries, fried potatoes, or potato chips.)11. During the past 7 days, how many times did you eat carrots?12. During the past 7 days, how many times did you eat other vegetables? (Donot count green salad, potatoes, or carrots.)Who is the target audience?Children in 3rd and 8 th grades for Network Youth surveyHigh School Students for Network High School SurveyNetwork Youth Survey 84

Additional informationNetwork Youth Survey 85

References1. Thiagarajah K, Fly AD, Hoelscher DM, Bai Y, Lo K, Leone A, Shertzer JA.Validating the food behavior questions from the elementary school SPANquestionnaire. J Nutr Ed Behav. 2006; 38/ 4; S552. Penkilo M, George G, Hoelscher DM. Reproducibility of the School BasedNutrition Monitoring Questionnaire among Fourth Grade Students in Texas. JNutr Ed Behav. 2008: 40/1; 20-273. Hoelscher,D.M., Day, R.S., Kelder, S.H. & Ward, J.L. (2003) Reproducibilityand validity of the secondary level School-Based Nutrition Monitoring studentquestionnaire. Journal of American Dietetic Association, 103(2),186-94.4 . Vereecken AC, Damme WV, Maes L. Measuring Attitudes, Self-Efficacy, andSocial and Environmental Influences on Fruit and Vegetable Consumption of 11-and 12-Year-Old Children: Reliability and Validity. J. Am Dietetic Association.2005; 105(2) 257-261.5. Hearn DH, Baranowski T, Baranowski J, Doyle C, Smith M, Lin LS, ResnicowK. Environmental Influences on Dietary Behavior Among Children: Availabilityand Accessibility of Fruits and Vegetables Enable Consumption. Journal ofHealth Education 1998; 29(1): 26-32.Network Youth Survey 86

Write your Identification Number here: _________________________Date:Network for a Healthy CaliforniaNetwork Youth SurveyThis survey was adapted from the School Physical Activity and Nutrition Project(SPAN – University of Texas) and the Fruits and Veggies More Matters ®Consumption Survey (Arizona Nutrition Network)by the Research and Evaluation Unitof the Network for a Healthy CaliforniaConfidentiality information to be explained to studentsWe would like for you to complete this survey. You may skip questions you do not want to answerbut we hope that you will answer all of them. Any information about who you are will be keptsecret. We will not share your name or identification number. They will only be used for reports.Funded by the U.S. Department of AgricultureFood Stamp Program, an equal opportunityprovider and employer, through the Network fora Healthy California.Network Youth Survey 87

Directions: This is a survey to find out about what you know, like, think and doabout healthy eating. Fill in the bubble (O) of the one best answer for eachquestion. Do NOT write your name anywhere on this survey.1. How old are you? O 6 O 7 O 8 O 9 O 10 O 11 O 12 O 13 O 14O 152. Are you a boy or a girl? O Boy O Girl3. Yesterday, did you drink any kind of milk? Count chocolate or other flavoredmilk, milk on cereal, or drinks made with milk.O No, I didn’t drink any milk yesterday.O Yes, I drank milk 1 time yesterday.O Yes, I drank milk 2 times yesterday.O Yes, I drank milk 3 or more times yesterday.4. Yesterday, did you eat yogurt or cottage cheese or string cheese or drink ayogurt drink?O No, I didn’t eat any of these foods yesterday.O Yes, I ate one of these foods 1 time yesterday.O Yes, I ate one of these foods 2 times yesterday.O Yes, I ate one of these foods 3 or more times yesterday.Network Youth Survey 88

5. Yesterday, did you eat any hot or cold cereal?O No, I didn’t eat any cereal yesterday.O Yes, I ate cereal 1 time yesterday.O Yes, I ate cereal 2 times yesterday.O Yes, I ate cereal 3 or more times yesterday.6. Yesterday, did you eat French fries or chips? Chips are potato chips, tortillachips, corn chips, or other snack chips.O No, I didn’t eat any French fries or chips yesterday.O Yes, I ate French fries or chips 1 time yesterday.O Yes, I ate French fries or chips 2 times yesterday.O Yes, I ate French fries or chips 3 or more times yesterday.7. Yesterday, did you eat any vegetables? Vegetables are all cooked anduncooked vegetables; salads; and boiled, baked and mashed potatoes. Do notcount French fries or chips.O No, I didn’t eat any vegetables yesterday.O Yes, I ate vegetables 1 time yesterday.O Yes, I ate vegetables 2 times yesterday.O Yes, I ate vegetables 3 times yesterday.O Yes, I ate vegetables 4 times yesterday.O Yes, I ate vegetables 5 or more times yesterday.Network Youth Survey 89

8. Yesterday, did you eat fruit? Include fresh, frozen or canned. Do not countfruit juice.O No, I didn’t eat any fruit yesterday.O Yes, I ate fruit 1 time yesterday.O Yes, I ate fruit 2 times yesterday.O Yes, I ate fruit 3 times yesterday.O Yes, I ate fruit 4 times yesterday.O Yes, I ate fruit 5 or more times yesterday.9. Yesterday, did you drink any punch, sports drinks or other fruit-flavoreddrinks? Do not count 100% fruit juice or diet drinks.O No, I didn’t drink any of these drinks yesterday.O Yes, I drank one of these drinks 1 time yesterday.O Yes, I drank one of these drinks 2 times yesterday.O Yes, I drank one of these drinks 3 or more times yesterday.10. Yesterday, did you drink fruit juice? Fruit juice is a drink, which is 100%juice, like orange juice, apple juice, or grape juice.O No, I didn’t drink any fruit juice yesterday.O Yes, I drank fruit juice 1 times yesterday.O Yes, I drank fruit juice 2 time yesterday.O Yes, I drank fruit juice 3 times yesterday.O Yes, I drank fruit juice 4 times yesterday.O Yes, I drank fruit juice 5 or more times yesterday.11. Yesterday, did you drink any regular (not diet) sodas or soft drinks?O No, I didn’t drink any regular (not diet) sodas or soft drinks yesterday.O Yes, I drank regular (not diet) sodas or soft drinks 1 time yesterday.O Yes, I drank regular (not diet) sodas or soft drinks 2 times yesterday.Network Youth Survey 90

O Yes, I drank regular (not diet) sodas or soft drinks 3 or more timesyesterday.12. Yesterday, did you eat sweet rolls, doughnuts, cookies, brownies, pies, orcake?O No, I didn’t eat any of these foods yesterday.O Yes, I ate one of these foods 1 time yesterday.O Yes, I ate one of these foods 2 times yesterday.O Yes, I ate one of these foods 3 or more timesyesterday.13. Below, check the days you exercised or took part in physical activity that made yourheart beat fast and made you breathe hard for at least 60 minutes?Examples are: basketball, soccer, running or jogging, fast dancing, swimming,bicycling, jumping rope, trampoline, hockey, fast skating, or rollerblading.O I didn’t do any exercise last week that made my heart beat fast for 60minutesO MondayO TuesdayO WednesdayO ThursdayO FridayO SaturdayO Sunday14. Below, check the days you play outdoors for at least 30 minutes?Do not count outdoor play during school hours.O I didn’t play outdoors last week.O MondayO TuesdayO WednesdayNetwork Youth Survey 91

O ThursdayO FridayO SaturdayO Sunday15. Yesterday, did you eat breakfast?O YesO No16. I like to try new foods.O Almost always or alwaysO SometimesO Almost never or neverThe questions in this next section ask how often your parents eat fruit andvegetables. Please bubble in one answer to each question.17. How often do your parents eatfruit?18. How often do your parents eatvegetables?NeverA fewdays aweekMostdays aweekEverydayI don’tknowO O O O OO O O O OThe questions in this next section ask why you may or may not eat fruitsand vegetables. Please fill in one answer for each question.19. At your home do you have fruits to eat?O NeverO SometimesO AlwaysO I don’t know20. At your home do you have vegetables to eat?O NeverO SometimesO AlwaysO I don’t knowNetwork Youth Survey 92

Thank youNetwork Youth Survey 93

Escribe tu número de identificación aquí: _________________________Fecha:Red para una California SaludableEncuesta para JóvenesEsta encuesta es una adaptación del proyecto de School Physical Activity andNutrition (SPAN – de la Universidad de Tejas) y de la encuesta del consumo deFruit and Veggies More Matters® (La Red de Nutrición de Arizona)por la Unidad de Investigación y Evaluaciónde la Red para una California SaludableExplicación a los estudiantes sobre la confidencialidad deinformaciónNos gustaría que contestaras esta encuesta. Si hay preguntas que no deseas contestar, no lascontestes, aunque esperamos las contestes todas. Toda información sobre ti será confidencial.No compartiremos tu nombre o número de identificación. Sólo se usarán para los reportes.Para información nutricional, visite www.campeonesdelcambio.net.Para información sobre los Cupones para Alimentos, llame al 877-847-3663. Financiado por el Supplemental Nutrition AssistanceProgram del Departamento de Agricultura de los Estados Unidos,un proveedor y empleador que ofrece oportunidades equitativas.Network Youth Survey 94

Instrucciones: Esta es una encuesta para conocer lo que sabes, te gusta,piensas y haces sobre los hábitos saludables al comer. Rellena la burbuja (O) dela respuesta que mejor te parezca en cada pregunta. NO escribas tu nombre enninguna parte de esta encuesta.1. ¿Qué edad tienes? O 6 O 7 O 8 O 9 O 10 O 11 O 12 O 13 O 14O 152. ¿Eres niño o niña? Niño O O Niña3. ¿Tomaste leche de cualquier tipo ayer? La leche con sabor a chocolate uotro sabor, la leche con cereal, o bebidas hechas con leche también cuentan.O No, ayer no tomé leche.O Sí, ayer tomé leche 1 vez.O Sí, ayer tomé leche 2 veces.O Sí, ayer tomé leche 3 o más veces.4. ¿Comiste yogur, queso cottage, tiritas de queso (string cheese) o algunabebida de yogur ayer?O No, ayer no comí ninguna de estas comidas.O Sí, ayer comí una de estas comidas 1 vez.O Sí, ayer comí una de estas comidas 2 veces.O Sí, ayer comí una de estas comidas 3 o más veces.Network Youth Survey 95

5. ¿Comiste cereal caliente o frío ayer?O No, ayer no comí ningún tipo de cereal.O Sí, ayer comí cereal 1 vez.O Sí, ayer comí cereal 2 veces.O Sí, ayer comí cereal 3 o más veces.6. ¿Comiste papas a la francesa o papitas ayer? Las “papitas” pueden ser depapas, tortilla, maíz o cualquier otro tipo de papitas.O No, ayer no comí papas a la francesa ni papitas.O Sí, ayer comí papas a la francesa o papitas 1 vez.O Sí, ayer comí papas a la francesa o papitas 2 veces.O Sí, ayer comí papas a la francesa o papitas 3 o más veces.7. ¿Comiste algún tipo de verdura ayer? La verdura puede ser cocida o cruda;ensaladas, papa al horno o puré de papa. Las papas a la francesa o papitasno cuentan.O No, ayer no comí ningún tipo de verdura.O Sí, ayer comí verdura 1 vez.O Sí, ayer comí verdura 2 veces.O Sí, ayer comí verdura 3 veces.O Sí, ayer comí verdura 4 veces.O Sí, ayer comí verdura 5 o más veces.Network Youth Survey 96

8. ¿Comiste fruta ayer? Incluye fruta fresca, congelada o enlatada. El jugo defrutas no cuenta.O No, ayer no comí ninguna fruta.O Sí, ayer comí fruta 1 vez.O Sí, ayer comí fruta 2 veces.O Sí, ayer comí fruta 3 veces.O Sí, ayer comí fruta 4 veces.O Sí, ayer comí fruta 5 o más veces.9. ¿Tomaste algún ponche, bebida deportiva u otro tipo de bebida con sabor afruta? El jugo de fruta 100% natural o bebidas dietéticas no cuentan.No, ayer no tomé ninguna de estas bebidas.Sí, ayer tomé una de estas bebidas 1 vez.Sí, ayer tomé una de estas bebidas 2 veces.Sí, ayer tomé una de estas bebidas 3 o más veces.10. ¿Tomaste jugo de fruta ayer? El jugo de fruta es una bebida que es 100%natural como el jugo de naranja, manzana o uva.O No, ayer no tomé ningún jugo de fruta.O Sí, ayer tomé jugo de fruta 1 vez.O Sí, ayer tomé jugo de fruta 2 veces.O Sí, ayer tomé jugo de fruta 3 veces.O Sí, ayer tomé jugo de fruta 4 veces.O Sí, ayer tomé jugo de fruta 5 o más veces.11. ¿Tomaste algún refresco (soda) regular (no dietético) ayer?O No, ayer no tomé ningún refresco (soda) regular (no dietético).O Sí, ayer tomé refresco (soda) regular (no dietético) 1 vez.Network Youth Survey 97

O Sí, ayer tomé refresco (soda) regular (no dietético) 2 veces.O Sí, ayer tomé refresco (soda) regular (no dietético) 3 o más veces.12. ¿Comiste galletas, panecillos, donas o pastel ayer?O No, ayer no comí ninguna de estas comidas.O Sí, ayer comí una de estas comidas 1 vez.O Sí, ayer comí una de estas comidas 2 veces.O Sí, ayer comí una de estas comidas 3 o más veces.13. Marca en qué días de los que están abajo hiciste ejercicio o participaste enalguna actividad física que hizo que tu corazón latiera rápido y te hizorespirar más fuerte por lo menos 60 minutos.Por ejemplo: básquetbol, fútbol, correr, bailar, nadar, andar en bicicleta,brincar lacuerda, brincar en el trampolín, hockey, o patinar rápidamente.O La semana pasada, no hice ningún tipo de ejercicio que hiciera que micorazón latiera rápido por 60 minutosO LunesO MartesO MiércolesO JuevesO ViernesO SábadoO Domingo14. Marca abajo en qué días jugaste al aire libre por lo menos 30 minutos.Jugar al aire libre en horas de escuela no cuenta.O La semana pasada no jugué al aire libre.O LunesO MartesO MiércolesO JuevesNetwork Youth Survey 98

O ViernesO SábadoO Domingo15. ¿Desayunaste ayer?O SíO No16. Me gusta probar comidas nuevasO Casi siempre o siempreO A vecesO Casi nunca o nuncaLas siguientes preguntas son referentes a tus padres. Por favor rellena laburbuja para contestar cada pregunta.CasiAlgunos todos Todos No séNunca días de lasemanalos díasde lasemanalosdías17. ¿Qué tan seguido comen frutatus papás?O O O O O18. ¿Qué tan seguido comenverduras tus papás?O O O O OLas siguientes preguntas son para saber por qué o por qué no comes frutay verdura. Por favor rellena una de las burbujas para contestar cada pregunta.19. ¿Hay frutas para comer en tu casa?O NuncaO A vecesO SiempreO No sé20. ¿Hay verduras para comer en tu casa?O NuncaO A vecesO SiempreO No séNetwork Youth Survey 99

GraciasNetwork Youth Survey 100

Write your Identification Number here: _________________________Date:Network for a Healthy CaliforniaNetwork High School SurveyThis survey was adapted from the School Physical Activity and Nutrition Project(SPAN – University of Texas) and the Fruits and Veggies More Matters ®Consumption Survey (Arizona Nutrition Network)by the Research and Evaluation Unitof the Network for a Healthy CaliforniaConfidentiality information to be explained to studentsWe would like for you to complete this survey. You may skip questions you do not want to answerbut we hope that you will answer all of them. Any information about who you are will be keptsecret. We will not share your name or identification number. They will only be used for reports.Funded by the U.S. Department of AgricultureFood Stamp Program, an equal opportunityprovider and employer, through the Network fora Healthy California.Network High School Survey 101

Directions: This is a survey to find out about what you know, like, think and doabout healthy eating. Fill in the bubble (O) of the one best answer for eachquestion. Do NOT write your name anywhere on this survey.1. How old are you? O 6 O 7 O 8 O 9 O 10 O 11 O 12 O 13 O 14O 152. Are you a boy or a girl? O Boy O Girl3. Yesterday, did you drink any kind of milk? Count chocolate or other flavoredmilk, milk on cereal, or drinks made with milk.O No, I didn’t drink any milk yesterday.O Yes, I drank milk 1 time yesterday.O Yes, I drank milk 2 times yesterday.O Yes, I drank milk 3 or more times yesterday.4. Yesterday, did you eat yogurt or cottage cheese or string cheese or drink ayogurt drink?O No, I didn’t eat any of these foods yesterday.O Yes, I ate one of these foods 1 time yesterday.O Yes, I ate one of these foods 2 times yesterday.O Yes, I ate one of these foods 3 or more times yesterday.Network High School Survey 102

5. Yesterday, did you eat any hot or cold cereal?O No, I didn’t eat any cereal yesterday.O Yes, I ate cereal 1 time yesterday.O Yes, I ate cereal 2 times yesterday.O Yes, I ate cereal 3 or more times yesterday.6. Yesterday, did you eat French fries or chips? Chips are potato chips, tortillachips, corn chips, or other snack chips.O No, I didn’t eat any French fries or chips yesterday.O Yes, I ate French fries or chips 1 time yesterday.O Yes, I ate French fries or chips 2 times yesterday.O Yes, I ate French fries or chips 3 or more times yesterday.7. During the past 7 days, how many times did you drink 100% fruit juices suchas orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid,sports drinks, or other fruit-flavored drinks.)OOOOOOOI did not drink 100% fruit juice during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 time per day2 times per day3 times per day4 or more times per dayNetwork High School Survey 103

8. During the past 7 days, how many times did you eat fruit? (Do not count fruitjuice.)OOOOOOOI did not eat fruit during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 time per day2 times per day3 times per day4 or more times per day9. During the past 7 days, how many times did you eat green salad?OOOOOOOI did not eat green salad during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 time per day2 times per day3 times per day4 or more times per day10. During the past 7 days, how many times did you eat potatoes? (Do notcount french fries, fried potatoes, or potato chips.)OOOOOOOI did not eat potatoes during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 time per day2 times per day3 times per day4 or more times per day11. During the past 7 days, how many times did you eat carrots?O I did not eat carrots during the past 7 daysO 1 to 3 times during the past 7 daysO 4 to 6 times during the past 7 daysO 1 time per dayO 2 times per dayO 3 times per dayNetwork High School Survey 104

O4 or more times per day12. During the past 7 days, how many times did you eat other vegetables? (Donot count green salad, potatoes, or carrots.)OOOOOOOI did not eat other vegetables during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 time per day2 times per day3 times per day4 or more times per day13. Yesterday, did you drink any punch, sports drinks or other fruit-flavoreddrinks? Do not count 100% fruit juice or diet drinks.O No, I didn’t drink any of these drinks yesterday.O Yes, I drank one of these drinks 1 time yesterday.O Yes, I drank one of these drinks 2 times yesterday.O Yes, I drank one of these drinks 3 or more times yesterday.14. Yesterday, did you drink any regular (not diet) sodas or soft drinks?O No, I didn’t drink any regular (not diet) sodas or soft drinks yesterday.O Yes, I drank regular (not diet) sodas or soft drinks 1 time yesterday.O Yes, I drank regular (not diet) sodas or soft drinks 2 times yesterday.O Yes, I drank regular (not diet) sodas or soft drinks 3 or more timesyesterday.15. Yesterday, did you eat sweet rolls, doughnuts, cookies, brownies, pies, orcake?O No, I didn’t eat any of these foods yesterday.O Yes, I ate one of these foods 1 time yesterday.O Yes, I ate one of these foods 2 times yesterday.O Yes, I ate one of these foods 3 or more timesNetwork High School Survey 105

yesterday.16. Below, check the days you exercised or took part in physical activity thatmade your heart beat fast and made you breathe hard for at least 60minutes?Examples are: basketball, soccer, running or jogging, fast dancing,swimming, bicycling, jumping rope, trampoline, hockey, fast skating, orrollerblading.O I didn’t do any exercise last week that made my heart beat fast for 60minutesO MondayO TuesdayO WednesdayO ThursdayO FridayO SaturdayO Sunday17. Below, check the days you play outdoors for at least 30 minutes?Do not count outdoor play during school hours.O I didn’t play outdoors last week.O MondayO TuesdayO WednesdayO ThursdayO FridayO SaturdayO SundayNetwork High School Survey 106

18. Yesterday, did you eat breakfast?O YesO No19. I like to try new foods.O Almost always or alwaysO SometimesO Almost never or neverThe questions in this next section ask how often your parents eat fruit andvegetables. Please bubble in one answer to each question.20. How often do your parents eatfruit?21. How often do your parents eatvegetables?NeverA fewdays aweekMostdays aweekEverydayI don’tknowO O O O OO O O O OThe questions in this next section ask why you may or may not eat fruitsand vegetables. Please fill in one answer for each question.22. At your home do you have fruits to eat?O NeverO SometimesO AlwaysO I don’t know23. At your home do you have vegetables to eat?O NeverO SometimesO AlwaysO I don’t knowThank youNetwork High School Survey 107

Nutrition Education SurveyThis Nutrition Education Survey (NES) was developed is to assess theimpact of nutrition education delivered to food stamp eligible persons. The NESis a modular tool that contractors can customize to fit the specific nutritioneducation activities delivered as part of their SOW. It has sets of questions thatwill capture change in perceived peer behavior, perceived parental support, selfefficacy,outcome expectations, socialization-encouragement, access,consumption, physical activity, knowledge and preferences. The sets areidentified in the paragraphs below and can be extracted to fit an intervention.Questions 1-6 were adapted from Vereecken et al. (2005) to measureperceived peer behavior. The original survey was validated with 11-12 year oldsin Belgium and the current version was adapted by the University of CA LosAngeles for students in the Los Angeles Unified School District. The originalquestions were changed to reduce the number of response categories and makethe language appropriate for CA students. For example, the original surveyincluded the question: How often does your best friend consume fruit? Theresponse categories were: never, less than once a week, once a week, 2-4days/week, 5-6 days/week, once a day, every day and every day, more thanonce. The adapted question reads: Does your best friend eat fruit everyday?There are three response categories: Yes, No, I don’t know.Questions 7 and 8 measure the child’s perceived parental support(Vereecken, 2005). The original survey had four questions that measure this. Forexample: How often does your father eat fruit? Response categories were: never,less than once a week, once a week, 2-4 days/week, 5-6 days/week, once a day,every day and every day, more than once; don't have or see mother/father. TheNES has two questions including: How often do your parents eat fruit? Responsecategories: never, a few days of the week, most days of the week, every day.Questions 9-16 were taken from a study (Baranowski et al., 2000) of theGimme 5 intervention and measure self-efficacy for asking and shopping for fruitand vegetables. These were validated with data from a three year outcomeevaluation of 3rd-5th graders.Questions 17-23 measure outcome expectations and were adapted fromitems developed by Reynolds et al. (2002) for 4th graders. The original 12-itemscale was reduced to seven items to be more consistent with the content ofHOTM. In Reynolds’ original study, the questions were validated data werecollected over a three year period from students at the end of their 3rd grade andbeginning of their 5th.Questions 24-31 measure socialization-encouragement. These werechanged from parents on the original survey (Veerecken et al., 2005) to teachers.These will help gauge the influence of teachers on students.NES 108

Questions 32-33 These questions measure students’ report of dailyaccess to fruit and vegetables in the home. These were adapted from Hearn’swork (1998) with 4 th and 5 th graders.Questions 34-36 measure consumption. They were validated byHoelscher et al. (2003) with 8 th graders as part of the School and PhysicalActivity Nutrition Project (SPAN). Thiagarajah (2006) reported moderate to goodreliability with 4 th graders.Questions 37-38 capture Physical activity. Prochaska et al. (2001)validated the 2-item PACE Survey with 12 year olds to determine the number ofdays children were active for at least 60 minutes. The response categories rangefrom zero days to seven days.Question 39 measures preferences. The items included on thepreferences list, adapted from Domel’s (1993), work with 4 th and 5 th graderswere selected at random as an example of what might be included in that sectionof the survey. This section may be modified to measure change in the itemsfeatured or gauge the preferences of other fruit and vegetables.When choosing the items to include it’s important to remember that theHOTM Cycle I items (apples, pears, kiwifruit, sweet potatoes, oranges, broccoli,spinach, carrots, strawberries, salad greens, grapes and green beans) are wellliked and well known, leaving little room for improvement. Given the high scoresthis section may not be a good measure of success. However, it might providereally interesting information about a group’s actual preferences and familiarityfor certain items, even if they are not featured in an intervention.Questions 40-44 measure knowledge. Information imparted duringnutrition education activities may be very unique to individual interventions. Manynutrition education activities do not naturally address the five knowledgequestions included on the survey. Consequently they would not be a goodmeasure of success. When including knowledge questions on a survey it isimportant to ensure they match the information delivered in the intervention.Questions 45-48 capture demographic characteristics. These can be usedfor analysis by gender, age, ethnicity and grade level and reporting to USDA.NES 109

ReferencesBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L,Wang DT. Gimme 5 fruit and vegetables for fun and health: OutcomeEvaluation. Health Education & Behavior 2000; 27(1):96-111.Domel SB, Baranowski T, Davis H, Leonard SB, Riley P, Baranowski J:Measuring fruit and vegetable preferences among fourth and fifth gradestudents. Prev Med 1993: 22(6): 866-879.Hearn DH, Baranowski T, Baranowski J, Doyle C, Smith M, Lin LS, Resnicow K.Environmental Influences on Dietary Behavior Among Children:Availability and Accessibility of Fruits and Vegetables EnableConsumption. Journal of Health Education 1998; 29(1): 26-32.Hoelscher DM, Day RS, Kelder SH, Ward JL. Reproducibility and validity of thesecondary level school-based nutrition monitoring student questionnaire.J. Am Dietetic Association: 2003:103(2)186-194.Prochaska, J.J., Sallis, J.F., & Long, B. A physical activity screening measure foruse with adolescents in primary care. Archives of Pediatric andAdolescent Medicine: 2001 (155) 554-559.Reynolds K, Yaroch A, et al. Testing mediating variables in a school-basednutrition intervention program. Health Psychol 2002; 21(1): 51-60.Thiagarajah K, Bai Y, Lo A, Leone A, Shertzer JA, Hoelscher DM, Fly. Assessingvalidity of food behavior questions from the School Physical Activity andNutrition Questionnaire. J Nut Ed Beh, Volume 38, Issue 4, July-August2006; Pages S55-S55.Vereecken AC, Damme WV, Maes L. Measuring Attitudes, Self-Efficacy, andSocial and Environmental Influences on Fruit and Vegetable Consumptionof 11- and 12-Year-Old Children: Reliability and Validity. J. Am DieteticAssociation. 2005; 105(2) 257-261.NES 110

Write your Identification Number here: _________________________Nutrition Education SurveyNES2008-09Prepared bythe Research and Evaluation Unitof the Network for a Healthy CaliforniaConfidentiality information to be explained to studentsWe would like for you to complete this survey. You may skip questions you do not want to answerbut we hope that you will answer all of them. Any information about who you are will be keptsecret. We will not share your name or identification number. They will only be used for reports.Funded by the U.S. Department of AgricultureFood Stamp Program, an equal opportunityprovider and employer, through the Network fora Healthy California.Directions: This is a survey to find out about what you know, like, think and do abouthealthy eating and fruits and vegetables. Fill in the bubble (O) of the one bestanswer for each question. Do NOT write your name anywhere on this survey.NES 111

The questions in this section ask what your friends think about eatingvegetables and fruit. Please bubble in one answer to each question.YesNoI don’tknow1. Do most of your friends like to eat fruit? O O O2. Do most of your friends eat fruit everyday?3. Does your best friend eat fruiteveryday?4. Do most of your friends like to eatvegetables?5. Do most of your friends eat vegetablesevery day?6. Does your best friend eat vegetableseveryday?O O OO O OO O OO O OO O OThe questions in this next section ask how often your parents eat fruit andvegetables. Please bubble in one answer to each question.NeverA fewdays aweekMostdays aweekEverydayIdon’tknow7. How often do your parentseat fruit?8. How often do your parentseat vegetables?O O O O OO O O O ONES 112

The questions in this next section ask how sure you are that you can ask andshop for fruit and vegetables. Please bubble in one answer to each question.How sure are you that you can:9. write my favorite fruit or vegetable on thefamily’s shopping list10. ask someone in my family to buy myfavorite fruit or vegetable11. go shopping with my family for my favoritefruit or vegetable12. pick out my favorite fruit or vegetable at thestore and put it in the shopping basket13. ask someone in my family to make myfavorite vegetable dish for dinner14. ask someone in my family to serve myfavorite fruit at dinner15. ask someone in my family to have fruits andfruit juices out where I can reach them16. ask someone in my family to havevegetables cut up out where I can reachthemI disagreeverymuchI disagreea littleI am notsureI agree alittleI agreeverymuchO O O O OO O O O OO O O O OO O O O OO O O O OO O O O OO O O O OO O O O ONES 113

The questions in this section are about what you think will happen if you eat fruitand vegetables. Tell us how much do you agree or disagree with the followingstatements? Please bubble in one answer for each question.Disagree Not Sure Agree17. I will have more energy for playing (sports, recessor after school) if I eat fruits and vegetables.18. I will get sick more often if I don’t eat fruits andvegetables.O O OO O O19. Eating fruits and vegetables will help me grow. O O O20. I will have healthier skin if I eat fruits andvegetables.21. If I eat fruits and vegetables, I will have strongereyes.22. If I eat fruits or vegetables at breakfast, I will beable to think better in class.23. Eating fruits and vegetables may help keep mefrom getting cavities.O O OO O OO O OO O ONES 114

The questions in this next section ask what your teacher tells you abouteating fruit and vegetables. Please bubble in one answer to each question.Does your teacher tell you… Yes NoI don’tknow24. … that vegetables are good for you O O O25. … that vegetables are healthy O O O26. …that vegetables taste good O O O27. …to eat vegetables every day O O O28. …that fruit is good for you O O O29. …that fruit is healthy O O O30. …that fruit tastes good O O O31. …to eat fruit every day O O OThe questions in this next section ask why you may or may not eat fruitsand vegetables. Please fill in one answer for each question.32. At your home do you have fruits to eat?O NeverO SometimesO AlwaysO I don’t know33. At your home do you have vegetables to eat?O NeverO SometimesO AlwaysO I don’t knowNES 115

The next set of questions is about how much you eat. (Please bubble your answer)34. Yesterday, did you eat any vegetables?Vegetables are all cooked and uncooked vegetables; salads; and boiled, baked andmashed potatoes.Do not count French fries or chips.O No, I didn’t eat any vegetables yesterday.O Yes, I ate vegetables 1 time yesterday.O Yes, I ate vegetables 2 times yesterday.O Yes, I ate vegetables 3 or more times yesterday.35. Yesterday, did you eat fruit?Do not count fruit juice.O No, I didn’t eat any fruit yesterday.O Yes, I ate fruit 1 time yesterday.O Yes, I ate fruit 2 times yesterday.O Yes, I ate fruit 3 or more times yesterday.36. Yesterday, did you drink fruit juice?Fruit juice is a 100% juice drink like orange juice, apple juice, or grape juice.Do not count punch, Kool-Aid®, sports drinks and other fruit-flavored drinks.O No, I didn’t drink any fruit juice yesterday.O Yes, I drank fruit juice 1 time yesterday.O Yes, I drank fruit juice 2 times yesterday.O Yes, I drank fruit juice 3 or more times yesterday.NES 116

Now we want to know how active you are. Add up all the time you spend inphysical activity each day (don't include your physical education or gymclass). Please bubble one answer for each question.Physical activity is any activity that increases your heart rate and makes you get outof breath some of the time.Physical activity can be done in sports, playing with friends, or walking to school.Some examples of physical activity are running, brisk walking, and rollerblading.37. Over the past 7 days, on how many days were you physically active for a total ofat least 60 minutes per day?O0 daysO1 DayO2 DaysO3 DaysO4 DaysO5 DaysO6 DaysO7 Days38. Over a typical or usual week, on how many days are you physically active for atotal of at least 60 minutes per day?O0 daysO1 DayO2 DaysO3 DaysO4 DaysO5 DaysO6 DaysO7 DaysNES 117

Now we want to know how much you like some foods. (Please bubble in your answer)39. How much do you likethese fruits andvegetables?I like this a lotI like this a little I do not like this I don’t know whatthis isAsparagus………Dried Plums ….O O O OO O O OGreen Beans….…O O O OKiwifruit................ O O O OMandarins .….…. O O O OMelons ……….. O O O OPersimmons…...O O O OSalad Greens…..O O O OSpinach………..O O O OSweet Potatoes… O O O ONES 118

In this section, we want you to tell us what you know about healthfuleating.Please bubble your answer40. Eating fruits and vegetables can help lower your chances of getting heartdisease or cancer.O TrueO FalseO Don’t know41. Fruits and vegetables that are high in Vitamin A are ____________ incolor.O Red and whiteO Blue and light brownO Yellow-orange and dark greenO Brown and purpleO I don’t know42. Almost all fruits and vegetables contain a lot vitamins and_______________.O ProteinO FiberO CholesterolO FatO Don’t know43. Which of the following fruits and vegetables are grown in California:O SpinachO ApplesO PearsO All of the above44. Fruits and vegetables, like apples and pears, are best when eaten with thepeel because that is where most of the fiber and antioxidants are.O TrueO FalseO Don’t knowNES 119

The last few questions are about you. Please bubble one answer for eachquestion.45. What grade are you in? (Fill in one answer)O 4 th grade O 7 th grade O 10 th gradeO 5 th grade O 8 th grade O 11 th gradeO 6 th grade O 9 th grade O 12 th grade46. How old are you? (Fill in one answer)O 8 years old O 12 years old O 16 years oldO 9 years old O 13 years old O 17 years oldO 10 years old O 14 years old O 18 years oldO 11 years old O 15 years old47. Are you a boy or a girl? (Fill in one answer)O BoyO Girl48. Are you Hispanic or Latino?O YesO No49. What is your race? (Select one or more responses.)O American Indian or Alaska NativeO AsianO Black or African AmericanO Native Hawaiian or Other Pacific IslanderO WhiteNES 120

Food Preferences SurveyTarget behaviorFruit and vegetable consumptionWhat is being measured?The factor of food preferences is strongly linked to fruit and vegetableconsumption (Domel, 1993, Baxter, 2002). Researchers have found that it takesabout eight exposures to a new food for a child to develop a preference for it.The survey that follows is comprised of a sample list of fruits, juices andvegetables. Monterey Department of Public Health contributed the Spanishversion of the survey.Who is the target audience?Children and adults: The survey was originally validated for use with thirdand fourth grade students. However, it may be used with adults served byNetwork contractors.Additional informationThe list of fruit and vegetables may be modified. The Networkrecommends that LIAs list the fruit and vegetables featured in the interventionand a few others to identify some that the target audience does not like or withwhich they are unfamiliar. The latter items can be used as targets for asubsequent intervention to increase preferences for a greater variety of items.The list should not include apples, grapes, kiwi, oranges, peaches, pearsor strawberries. The results from the 2005-06 evaluation showed that a group ofover 700 students, primarily 4 th and 5 th graders, were familiar with those itemsand liked them a lot. This would leave little room for improvement or change andd a good measure of program success or good use of survey space.There are several ways to analyze change in the summary scores forpreferences. The Network conducts two methods and only includes itemsfeatured in the intervention. The first answers the question: Did respondentsbecome familiar with fruits or vegetables that were previously unknown to them?This analysis would capture change in the proportion of respondents who movefrom “I don’t know what this is” to “I don’t like it”, I like it a little” or I like it a lot. AMcNemar test is appropriate for this analysis.The second question is: Did preferences change for those who knew whatthe item was? This analysis excludes those individuals who reported, at pretest,not knowing what the item was. The rationale is that those who cannot identify anitem do not have a preference for it. A paired t-test is used to capture movementwithin the three preference responses.Preferences 121

ReferencesCullen K, Baranowski T, et al. Availability, accessibility, and preferences for fruit,100% fruit juice, and vegetables influence children's dietary behavior. HealthEduc Behav 2003; 30(5): 615-26.Domel, S. B., T. Baranowski, et al. (1993). "Measuring fruit and vegetablepreferences among 4th- and 5th-grade students." Prev Med 22(6): 866-79.Baxter, S. D. and W. O. Thompson (2002). "Fourth-grade children's consumptionof fruit and vegetable items available as part of school lunches is closely relatedto preferences." J Nutr Educ Behav 34(3): 166-71.Preferences 122

How much do you like these fruits and vegetables? Please bubble your answer I like this a lotI like this a little I do not like this I don’t know whatthis isAsparagus……………. O O O OAvocados…………….. O O O OBeets………………….O O O OBroccoli………………. O O O OCabbage……………… O O O OCooked Greens……… O O O OCorn…………………. O O O ODried Plum…………… O O O OGrapefruit…………… O O O OGreen Beans………… O O O OMandarins(Tangerines)O O O OMelons………………. O O O OMushrooms………… O O O ONectarines…………… O O O OOnions………………… O O O OPersimmons………… O O O OPlums…………………. O O O ORadishes……………… O O O OSalad Greens………… O O O OSpinach……………… O O O OSweet Potatoes……… O O O OTomatoes…………… O O O OAre there other fruits that you really like? □ Yes → what kind?________________________Are there other vegetables that you really like? □ Yes → what kind?_____________________Food Preferences Surveys 123

Grade/Grado: 4 th 2Teacher/Maestro/a:Student ID/Numero de Identificación: ____________Food Preference Survey – Fruits and Vegetables Encuesta de Frutas Y VerdurasHow much do you like these fruits and vegetables? Please check your answer¿Cuánto te gusta la fruta y verdura? Por favor marca tu respuesta con una Fruits and Vegetables I like this a lot I like this a little I do not like this I don’t know what thisisFrutas y VerdurasMe gusta muchoMe gusta unpocoNo me gustaNo sé que es estoBanana/PlátanoO O O OBroccoli/Brocoli O O O OCabbage/Repollo O O O OCarrot/Zanahoria O O O OGreen bean/Ejote O O O OMushroom/Hongo O O O ONectarine/NectarinaO O O OOrange/Naranja O O O OPeach/Durazno O O O OPear/PeraPlum/CiruelaStrawberry/FresaO O O OO O O OO O O OTomato/Tomate O O O OWatermelon/Sandia O O O OZucchini/CalabacitaO O O OAre there other fruits that you really like? □ Yes → what kind?¿Hay otras frutas que te gustan mucho? □ Sí → ¿qué tipo?______________________Are there other vegetables that you really like? □ Yes → what kind?¿Hay otros vegetales que te gustan mucho? □ Sí → ¿qué tipo?_________________2 Translated by staff at Monterey County Health DepartmentFood Preferences Surveys 124

Food Security SurveysTarget behaviorUse of Nutrition Assistance ProgramsWhat is the behavior being measured?Food insecurity, food stamp utilization, and use of other food assistanceprograms.Who is the target audience?Adults onlyHow to use the USDA survey – User Notes (from the website referencedbelow)(1) Response Options: For interview surveys, DK (“don’t know”) and “Refused”are blind responses - that is, they are not presented as response options, butmarked if volunteered. For self-administered surveys, DK is presented as aresponse option.(2) Screeners: The two levels of screener are provided for survey administratorswishing to reduce respondent burden for households not manifesting: (a) anylevel of food insecurity (1 st -level screener); or (b) any signs of hunger (2 nd -levelscreener).To further reduce burden for higher-income respondents, a preliminaryscreener may be constructed using Q1 along with a household income measure.Households with income above twice the poverty threshold, AND who respond to Q1 may be skipped to the end of the module and classified as foodsecure. Use of this preliminary screener reduces total burden in a survey withmany higher-income households, and the cost, in terms of accuracy in identifyingfood insecure households, is not great. However, research has shown that asmall proportion of the higher-income households screened out by this procedurewill register food insecurity if administered the full module. If Q1 is not neededfor research purposes, a preferred strategy is to omit Q1 and administer Stage 1of the module to all households. Administration time for Stage 1 is very nearlythe same as administration time for the preliminary USDA food sufficiencyquestion/screener.Food Security Surveys 125

(3) 30-Day Reference Period: The questionnaire items may be modified to a30-day reference period by changing the “last 12-month” references to “last 30days.” In this case, items 8a, 12a, and 14a must be changed to read as follows:8a/12a/14a [IF YES ABOVE, ASK] In the last 30 days, how many daysdid this happen?______ days[ ] DK(4) Food-Security/Hunger Scale: Questions 2-16 provide a complete, validatedset of food-insecurity/hunger indicator variables for use in: (1) scaledmeasurement of the severity of household food insecurity and hunger; (2)classification of households by severity level of food insecurity and hunger; and(3) comparison of food-insecurity and hunger prevalence with nationalbenchmark data. To request guidance materials for calculating these measures,contact the U.S. Department of Agriculture, Food and Nutrition Service, Office ofAnalysis, Nutrition, and Evaluation, Alexandria, VA(703-305-2125), or the U.S. Department of Agriculture, Economic ResearchService, Washington, DC (202-694-5433).Items 1-6 of the California Women’s Health Survey Food AdequacyModule were validated as a short scale. They may be used alone or inconjunction with the other questions.The Short Form of the 12-month Food Security Scale contains sixquestions that can be used to measure “food secure,” “food secure withouthunger” and “food secure with hunger” in situations when time does not permituse of the 18-item survey. Keenen, et al. (2001) note that the scale does notaccurately assess very severe food insecurity in children but does gauge risk ofchild hunger.ReferencesUSDA items:Blumberg SJ, Bialostosky K, Hamilton WL, Briefel RR. The Effectiveness of aShort Form of the Household Food Security Scale. Am J Public Health 1999; 89:1231-1234.Available at:http://www.ers.usda.gov/Briefing/FoodSecurity/surveytools/FS_SHORT.docUSDA 2000 Guide to Measuring Household Food Security –http://www.ers.usda.gov/briefing/foodsecurity/surveytools/core0699.docCWHS items:Keenan DP, Olson C, Hersey JC, Parmer SM. Measures of food insecurity/security. J Nutr Educ Behav 2001; 33 Suppl 1:S049-58.Food Security Surveys 126

Food-Security/Hunger Core Module3-STAGE DESIGN, WITH SCREENERSUSDA, Food and Nutrition Service and Economic Research Service –6/23/99Transition into Module (administered to all households): These nextquestions are about the food eaten in your household in the last 12 months,since (current month) of last year and whether you were able to afford the foodyou need.USDA Food Sufficiency Question/Screener: Questions 1, 1a, 1b (Optional,these questions are not used to calculate the food-security/hunger scale.Question 1 may be used in conjunction with income as a preliminaryscreener to reduce respondent burden for high income households).1. [IF ONE PERSON IN HOUSEHOLD, USE "I" IN PARENTHETICALS,OTHERWISE, USE "WE."]Which of these statements best describes the food eaten in yourhousehold in the last 12 months: --enough of the kinds of food (I/we) wantto eat; --enough, but not always the kinds of food (I/we) want; --sometimesnot enough to eat; or, --often not enough to eat?[1] Enough of the kinds of food we want to eat (SKIP 1a and 1b)[2] Enough but not always the kinds of food we want (SKIP 1a)[3] Sometimes not enough to eat [SKIP 1b][4] Often not enough [SKIP 1b][ ] DK or Refused (SKIP 1a and 1b)1a. [IF OPTION 3 OR 4 SELECTED, ASK] Here are some reasons whypeople don't always have enough to eat. For each one, please tell me ifthat is a reason why YOU don't always have enough to eat. [READ LIST.MARK ALL THAT APPLY.]YES NO DK[ ] [ ] [ ] Not enough money for food[ ] [ ] [ ] Not enough time for shopping or cooking[ ] [ ] [ ] Too hard to get to the store[ ] [ ] [ ] On a diet[ ] [ ] [ ] No working stove available[ ] [ ] [ ] Not able to cook or eat because of health problemsFood Security/Hunger 127

1b. [IF OPTION 2 SELECTED, ASK] Here are some reasons why peopledon't always have the quality or variety of food they want. For each one,please tell me if that is a reason why YOU don't always have the kinds offood you want to eat. [READ LIST. MARK ALL THAT APPLY.]YES NO DK[ ] [ ] [ ] Not enough money for food[ ] [ ] [ ] Kinds of food (I/we) want not available[ ] [ ] [ ] Not enough time for shopping or cooking[ ] [ ] [ ] Too hard to get to the store[ ] [ ] [ ] On a special dietStage 1: Questions 2-6 (asked of all households; begin scale items).[IF SINGLE ADULT IN HOUSEHOLD, USE "I," "MY," AND “YOU” INPARENTHETICALS; OTHERWISE, USE "WE," "OUR," AND "YOURHOUSEHOLD."]2. Now I’m going to read you several statements that people have madeabout their food situation. For these statements, please tell me whetherthe statement was often true, sometimes true, or never true for (you/yourhousehold) in the last 12 months, that is, since last (name of currentmonth).The first statement is “(I/We) worried whether (my/our) food would run outbefore (I/we) got money to buy more.” Was that often true, sometimestrue, or never true for (you/your household) in the last 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or Refused3. “The food that (I/we) bought just didn’t last, and (I/we) didn’t have moneyto get more.” Was that often, sometimes, or never true for (you/yourhousehold) in the last 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or Refused4. “(I/we) couldn’t afford to eat balanced meals.” Was that often,sometimes, or never true for (you/your household) in the last 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or RefusedFood Security/Hunger 128

[IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q5 - 6; OTHERWISE SKIPTO 1 st -Level Screen.]5. “(I/we) relied on only a few kinds of low-cost food to feed (my/our) child/thechildren) because (I was/we were) running out of money to buy food.”Was that often, sometimes, or never true for (you/your household) in thelast 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or Refused6. “(I/We) couldn’t feed (my/our) child/the children) a balanced meal,because (I/we) couldn’t afford that.” Was that often, sometimes, or nevertrue for (you/your household) in the last 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or Refused1 st -level Screen (screener for Stage 2): If affirmative response to any one ofQuestions 2-6 (i.e., "often true" or "sometimes true"), OR, response [3] or [4] toQuestion 1 (if administered), then continue to Stage 2; otherwise, skip to end.Stage 2: Questions 7-11 (asked of hh's passing the 1 st -level Screen:estimated 40% of hh's < 185% Poverty; 5.5% of hh's > 185% Poverty; 19%of all households).[IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q7; OTHERWISE SKIP TOQ8]7. "(My/Our child was/The children were) not eating enough because (I/we)just couldn't afford enough food." Was that often, sometimes, or nevertrue for (you/your household) in the last 12 months?[ ] Often true[ ] Sometimes true[ ] Never true[ ] DK or RefusedFood Security/Hunger 129

8. In the last 12 months, since last (name of current month), did (you/you orother adults in your household) ever cut the size of your meals or skip mealsbecause there wasn't enough money for food?[ ] Yes[ ] No (Skip 8a)[ ] DK (Skip 8a)8a. [IF YES ABOVE, ASK] How often did this happen---almost every month,some months but not every month, or in only 1 or 2 months?[ ] Almost every month[ ] Some months but not every month[ ] Only 1 or 2 months[ ] DK9. In the last 12 months, did you ever eat less than you felt you shouldbecause there wasn't enough money to buy food?[ ] Yes[ ] No[ ] DK10. In the last 12 months, were you every hungry but didn't eat because youcouldn't afford enough food?[ ] Yes[ ] No[ ] DK11. In the last 12 months, did you lose weight because you didn't have enoughmoney for food?[ ] Yes[ ] No[ ] DK2 nd -level Screen (screener for Stage 3): If affirmative response to any one ofQuestions 7 through 11, then continue to Stage 3; otherwise, skip to end.Stage 3: Questions 12-16 (asked of hh's passing the 2 nd -level Screen:estimated 7-8% of hh's < 185% Poverty; 1-1.5% of hh's > 185% Poverty; 3-4% of all hh's).Food Security/Hunger 130

12. In the last 12 months, did (you/you or other adults in your household) evernot eat for a whole day because there wasn't enough money for food?[ ] Yes[ ] No (Skip 12a)[ ] DK (Skip 12a)12a. [IF YES ABOVE, ASK] How often did this happen---almost every month,some months but not every month, or in only 1 or 2 months?[ ] Almost every month[ ] Some months but not every month[ ] Only 1 or 2 months[ ] DK[IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK 13-16; OTHERWISE SKIPTO END.]13. The next questions are about children living in the household who areunder 18 years old. In the last 12 months, since (current month) of last year,did you ever cut the size of (your child's/any of the children's) meals becausethere wasn't enough money for food?[ ] Yes[ ] No[ ] DK14. In the last 12 months, did (CHILD’S NAME/any of the children) ever skipmeals because there wasn't enough money for food?[ ] Yes[ ] No (Skip 14a)[ ] DK (Skip 14a)14a. [IF YES ABOVE ASK] How often did this happen---almost every month,some months but not every month, or in only 1 or 2 months?[ ] Almost every month[ ] Some months but not every month[ ] Only 1 or 2 months[ ] DK15. In the last 12 months, (was your child/ were the children) ever hungry butyou just couldn't afford more food?[ ] Yes[ ] No[ ] DKFood Security/Hunger 131

16. In the last 12 months, did (your child/any of the children) ever not eat for awhole day because there wasn't enough money for food?[ ] Yes[ ] No[ ] DKEND OF FOOD-SECURITY/HUNGER CORE MODULEFood Security/Hunger 132

California Women’s Health Survey Food AdequacyModuleI’m going to read you a few statements that people have made about theirfood situation. For these statements, please tell me whether the statementwas OFTEN true, SOMETIMES true, or NEVER true for you in the last 12months. (That is, since MONTH of last year)Ask all women1a. The food that I bought just didn’t last, and I didn’t have money to getmore. TRUE FALSE1b. Was that OFTEN, SOMETIMES, or NEVER true for you in the last 12months? 1. Often 2. Sometimes, or 3. Never true 7. Don’t know / Not sure 9. Refused2. I couldn’t afford to eat balanced meals. Was that OFTEN, SOMETIMES,or NEVER true for you in the last 12 months? 1. Often 2. Sometimes, or 3. Never true 7. Don’t know / Not sure 9. Refused3. In the last 12 months, did you ever cut the size of your meals or skipmeals because there wasn’t enough money for food? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused4. How often did this happen? Was it almost every month, some monthsbut not every month, or, only in one or two months in the last 12months? 1. Almost every month 2. Some months, but not every month 3. Only in one or two months 7. Don’t know / Not sure 9. RefusedCalifornia Women’s Health Survey Food Adequacy Module 133

5. In the last 12 months, did you ever eat less than you felt you shouldbecause there wasn’t enough money to buy food? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused6. In the last 12 months, were you ever hungry but didn’t eat because youcouldn’t afford enough food? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused7. During the last 12 months, did you ever eat less than you wanted ornot eat at all so that some other member of your household wouldhave enough to eat? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused8. During the last 12 months, have you or others in your householddelayed getting medical treatment or filling prescriptions in order tobuy food? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused9. In the last twelve months, have you APPLIED FOR food stamps? 1. Yes 2. No 7. Don’t know / Not sure 9. RefusedCalifornia Women’s Health Survey Food Adequacy Module 134

10. In the past 12 months, were you denied food stamps? 1. Yes 2. No 7. Don’t know / Not sure 9. Refused11. In the last twelve months, have you RECEIVED and USED food stampsor an Advantage Card? 1. Yes (Go to Q12) 2. No (Go to Q13) 7. Don’t know / Not sure (Go to Q13) 9. Refused (Go to Q13)Ask if yes to question 1112. In an average month, how many days do food stamps last in yourhousehold? Less than 7 (< 1 week) 7 to 13 days (1-2 weeks) 14 to 20 days (2-3 weeks) 21-27 days (3-4 weeks) 28 – 30 days (all month) 77.Don’t know / Not sure (Go to 15) 99. Refused (Go to 15)13. What is the main reason you are not currently receiving food stamps? 1. Was denied (see 10 above) 2. Don't need them 3. Don’t think I'm eligible 4. Don't know how to get them 5. Too hard to apply 6. Don't want government help 7. Worried about my citizenship status or being a “public charge” 8. Too embarrassed to use them 9. Didn’t think about it 10. Didn’t qualify 11. Didn’t know about them 12. Other (describe) _____________________________________ 77. Don’t know / Not sure 99. RefusedCalifornia Women’s Health Survey Food Adequacy Module 135

In the last 12 months, have you or anyone in your household received foodassistance from any of the following sources? For each one, please tell meif you received food from the source named.YES NO Don’tknowRefused14. WIC (coupons/vouchers)? 1 2 7 915. Emergency food banks, foodpantry, soup kitchen16. Meals served at a foodkitchen/community site17. Senior meal site or homedeliveredmeals (1%)18. Free or reduced price schoolbreakfast19. Free or reduced price schoollunch 1 2 7 9 1 2 7 9 1 2 7 9 1 2 7 9 1 2 7 920. The Summer meal program 1 2 7 921. Would you say you have enough to eat? 1. Always 2. Most of the time 3. Sometimes 4. Rarely or never 7. Don’t know / Not sure 9. RefusedCalifornia Women’s Health Survey Food Adequacy Module 136

Short Form of the 12-month Food Security Scale - Questionnaire____________________________________________________________________________These next questions are about the food eaten in your household in the last 12 months andwhether you were able to afford the food you need.1 (54). I'm going to read you two statements that people have made about their food situation.Please tell me whether the statement was OFTEN, SOMETIMES, or NEVER true for(you/you or the other members of your household) in the last 12 months.The first statement is, "The food that (I/we) bought just didn't last, and (I/we) didn't havemoney to get more." Was that often, sometimes, or never true for (you/your household)in the last 12 months?(1) Often true(2) Sometimes true(3) Never true(D, R)_____________________________________________________________________________2 (55). "(I/we) couldn't afford to eat balanced meals." Was that often, sometimes, or never truefor (you/your household) in the last 12 months?(1) Often true(2) Sometimes true(3) Never true(D, R)_____________________________________________________________________________3 (24). In the last 12 months, since (date 12 months ago) did (you/you or other adults in yourhousehold) ever cut the size of your meals or skip meals because there wasn't enoughmoney for food?(1) Yes(2) No (GO TO 5)(D, R) (GO TO 5)______________________________________________________________________________4 (25). [Ask only if # 3 = YES] How often did this happen---almost every month, some monthsbut not every month, or in only 1 or 2 months?(1) Almost every month(2) Some months but not every month(3) Only 1 or 2 months(D, R)(X) Question not asked because of negative or missing response to question 3_____________________________________________________________________________5 (32). In the last 12 months, did you ever eat less than you felt you should because there wasn'tenough money to buy food?(1) Yes(2) No(D, R)6 (35). In the last 12 months, were you ever hungry but didn't eat because you couldn't affordenough food?(1) Yes(2) No(D, R)Short Form Food Security 137

Knowledge, Awareness & Beliefs SurveysTarget behaviorFruit and vegetable consumptionWhat is being measured?Knowledge is a factor related to behavior change but not sufficient byitself. The Network requires any contractor measuring knowledge to alsomeasure some other factor. The following surveys measure knowledge, beliefsand awareness related to fruit and vegetable intake.The two surveys that follow have been adapted from other surveysfocusing on general knowledge about nutrition and fruit and vegetableconsumption. The first three items of the general knowledge survey weredeveloped by Hoelscher, et al. (2004). Items 4-7 were used in a tool developedby Reynolds, et al. (2002) in the “High 5” intervention. The second survey isadapted from an instrument used by a Network contractor, the Hawthorne UnifiedSchool District (Russell, 2004). While this tool has not been validated, it may behelpful to other contractors implementing school-based interventions.The Fruit and Vegetable Inventory survey created by Townsend andKaiser contains 13 items that related to perceived benefits, control and dietaryquality; self-efficacy, and readiness to eat more fruits and vegetables.Who is the target audience?General Knowledge Survey: 4 th - 11 th gradesHawthorne Unified School District Student Knowledge Survey items: 3 rd -5 thgradesAdditional informationThe surveys may be modified (questions added or removed) to covertopics addressed by the intervention. Choose the survey that has questionssimilar to the content of the intervention. Also, consider the audience you targetwith your intervention and the one for which the survey items were developed.The correct answers should be added to get a summary score, which willrange between 0 and the total number of questions. The correct answers aremarked with a “1” and incorrect responses are marked with a “0”. The correctanswers to the questions on the survey by Reynolds and Holscher are as follows:Q1 = true; Q2 = true; Q3 = true; Q4 = Drink juice at breakfast 3 days this week;Q5 = Plain grilled chicken breast sandwich; Q6 = Order a side of salad; Q7 =Baked potato without toppings like butter. The correct answers to the survey byRussell are: Q1 = fiber; Q2 = yellow-orange and dark green; Q3 = fresh fruit; Q4= 100% fruit juice; Q5 = oranges.Knowledge, Attitudes, and Beliefs Surveys 138

ReferencesRussell, S. 2004. Validity and Reliability of a Knowledge survey for HawthorneUnified School District. Unpublished.Hoelscher D, Day RS, Lee ES, Frankowski RF, Kelder SH, Ward JL, ScheurerME.Measuring the prevalence of overweight in Texas school children. AmericanJournal of Public Health 2004; 94: 1002-1008.Reynolds K, Yaroch A, et al. Testing mediating variables in a school-basednutrition intervention program. Health Psychol 2002; 21(1): 51-60.Knowledge, Attitudes, and Beliefs Surveys 139

General Knowledge (Reynolds, Hoelscher)We want you to tell us what you know about healthful eating.Please check your answer1. What you eat can make a difference in your chances of getting heartdisease or cancer.1 True2 False3 Don’t know2. People who are overweight are more likely to have health problems thanpeople who are not overweight.1 True2 False3 Don’t know3. People who are underweight are more likely to have health problemsthan people who are who not underweight.1 True2 False3 Don’t know4. Which of these would be the best example of a SHORT-TERM Goal tohelp you begin to eat more fruits and vegetables?1 Eat fruit or drink juice every day for breakfast and lunch2 Try to eat more fruits and vegetables3 Drink juice at breakfast 3 days this week4 Don’t know5. Which of these would be the LOWEST Fat sandwich choice?1 Cheeseburger2 Tuna salad sandwich with mayonnaise3 Plain grilled chicken breast sandwich4 Don’t know6. Which of these would be the best way to add a fruit or vegetable to yourmeal at a fast food restaurant?1 Add a tomato slice to your hamburger2 Order apple pie for dessert3 Order a large serving of French fries4 Order a side of salad5 Don’t know7. Which of these is the HEALTHIEST way to eat potatoes?1 Potato salad2 French fries3 Baked potato without toppings like butter4 Don’t knowKnowledge (Hoelscher) 140

Hawthorne Unified School District (Russell)Student Knowledge SurveyDirections: This is a survey to find out what you know. Circle theletter of the one best answer.1. Fruits and vegetables contain vitamins and _________.a. proteinb. fiberc. cholesterold. fate. I don’t know2. Fruits and vegetables that are high in Vitamin A are ________ in color.a. red and whiteb. blue and light brownc. yellow-orange and dark greend. brown and purplee. I don’t know3. Which ONE of these foods is a healthy snack?a. Ice creamb. Potato chipsc. Fresh fruitd. Fruit Roll-upse. I don’t know4. The healthiest juice to buy has ___________ on the label.a. 100% fruit juiceb. contains fruit juicec. 100% fruit punchd. tastes greate. I don’t know5. A fruit salad will be higher in Vitamin C if you add _____ to it.a. applesb. grapesc. bananasd. orangese. I don’t knowKnowledge (Hawthorne) 141

Fruit and Vegetable InventoryTarget behaviorFruit and vegetable consumptionWhat is being measured?This survey measures six psychosocial factors related to fruit andvegetable consumption. They include perceived benefits, perceived control, selfefficacyfor eating fruit and vegetables, readiness to eat more fruit, readiness toeat more vegetables, and perceived diet quality.Who is the target audience?Low-income adultsAdditional informationThis survey also includes an instruction guide that is also available on thewebsite. The authors and the Network recommend that behavioral questions beadded to measure consumption. These might include the Food BehaviorChecklist or Fruit and Vegetable Checklist that are available athttp://townsendlab.ucdavis.edu.ReferencesTownsend MS, Kaiser LL. University of California Fruit and Vegetable Inventory.University of California Cooperative Extension, 2006. (English, 13-item 2-pageevaluation tool for low-income clients.Development of an evaluation tool to assess psychosocial indicators of fruit andvegetable intake for two federal program. J Nutrition Education & Behavior. 2005;37: 170-184.Townsend MS, Kaiser LL. Brief tool is sensitive to fruit and vegetable interventionin low-income communities. J American Dietetic Assoc. In press.Fruit and Vegetable Inventory 142

Full survey available from http://townsendlab.ucdavis.edu/Fruit and Vegetable Inventory 143

Norms Surveys for ChildrenTarget behaviorIncreasing fruit and vegetable consumptionWhat is being measured?Family and social norms are factors that influence an individual at theinterpersonal level. The surveys that follow have questions designed to captureshifts in a social network’s expectation of its member’s behavior. Small changesat levels such as this can have large changes on group behavior. The surveysbelow have been used to measure social and family norms.Who is the target audience?Children 9-11 yearsAdditional informationThese surveys were adapted from surveys that referred to servingsinstead of cups. They have not been validated with the new wording. To choosethe survey that is right for your program, look at the areas of norms that aretargeted by each survey. You want to be able to show that the interventionproduced a change in these norms. Choose a survey with questions that mostclosely match your intervention goals and one in which the students are mostlikely to answer “Disagree” or “Not Important” before the intervention and “Agree”or “A Very Good Thing” after the intervention.When analyzing this data the responses should be added to get asummary score for each participant. Higher scores represent better results.ReferencesBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, LinL, Wang DT. Gimme 5 fruit and vegetables for fun and health: OutcomeEvaluation. Health Education & Behavior 2000; 27(1):96-111.Norms 144

Social Norms (Baranowski, et al.)What do others think of eating fruits andvegetables?1. Most people in my family think that eating 1½ -2cups of fruit or juice each day is…2. Most people in my family think that eating 1½ -3 cups of vegetables each day is…3. Most kids my age think that eating 1½ -2 cupsof fruit or juice each day is…4. Most kids my age think that eating 1½ - 3 cupsof vegetables each day is…(Please check your answer)A verygoodthingA goodthingNotimportantI don’tknow4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 Family Norms (Reynolds, et al.)What do you think of the followingstatements?1. Most people in my family think that eating 3-5cups of fruits and vegetables each day is a goodthing for me to do.2. Most people in my family think that eating 1½-2 cups of fruit and juice each day is a goodthing for me to do.3. Most people in my family think that eating 1½-3 cups of vegetables each day is a good thingfor me to do.(Please check your answer)Disagree Uncertain Agree1 2 3 1 2 3 1 2 3 Norms 145

Outcome Expectations Surveys for ChildrenTarget behaviorIncreasing fruit and vegetable consumptionWhat is being measured?Outcome expectations are a way to measure what individuals perceive willhappen if they eat fruits and vegetables.Who is the target audience?ChildrenAdditional informationThe first set of questions were adapted from a survey developed byReynolds et al. (2002) for 4th graders. The original 12-item scale was reduced toseven items to be more consistent with the nutrition education delivered byNetwork contractors and USDA guidelines. For example, the question: fruits andvegetables will keep me from getting cancer was deleted. Also, the originalsurvey included a question that that read “eating fruit and vegetables will keepme from getting cavities.” The Network does not promote definitive cause andeffect statements such as this so the wording was changed to “may help” keepme from getting cavities. In Reynolds’ original study, the questions werevalidated data were collected over a three year period from students at the end oftheir 3rd grade and beginning of their 5th.Questions 1, 5, 11 and 13 of the Baranowski survey need to be reversecoded because the desired answers are on the low end of the scale.The last set of outcome expectations questions were part of the Schooland Idea Resource Kit. It is described above.ReferencesBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L,Wang DT. Gimme 5 fruit and vegetables for fun and health: OutcomeEvaluation. Health Education & Behavior 2000; 27(1):96-111.Reynolds K, Yaroch A, et al. Testing mediating variables in a school-basednutrition intervention program. Health Psychol 2002; 21(1): 51-60.Outcome Expectations 146

Outcome Expectations for Eating FVs (Reynolds)Disagree Not Sure Agree1. I will have more energy for playing (sports, recessor after school) if I eat fruits and vegetables.2. I will get sick more often if I don’t eat fruits andvegetables.O O OO O O3. Eating fruits and vegetables will help me grow. O O O4. I will have healthier skin if I eat fruits andvegetables.5. If I eat fruits and vegetables, I will have strongereyes.6. If I eat fruits or vegetables at breakfast, I will beable to think better in class.7. Eating fruits and vegetables may help keep mefrom getting cavities.O O OO O OO O OO O OOutcome Expectations (Reynolds et al.) 147

Outcome Expectations for Eating FVs (Baranowski, etal.)FRUITS AND VEGETABLES(IF I EAT)If I eat fruits and vegetables every day…I disagreeverymuchPlease choose your answer.Idisagreea littleI amnotsureI agreea little1. I will become stronger A B C D EI agreeverymuch2. my friends will start eating them too A B C D E3. I will have stronger eyes A B C D E4. I will have a nicer smile A B C D E5. I will be healthier A B C D E6. I will think better in class A B C D E7. it may help keep me from getting fat A B C D E8. I will have more energy A B C D E9. my family will be proud of me A B C D EOutcome Expectations (Baranowski et al.) 148

Self-Efficacy Surveys for ChildrenTarget behaviorFruit and vegetable consumptionWhat is being measured?The surveys that follow measure different areas of self-efficacy. The firstlooks at self-efficacy related to asking for and preparing fruits and vegetables.The second survey looks at self-efficacy for eating more fruits and vegetables atdifferent meals and snacks. The third asks questions about self-efficacy forasking and shopping for fruits and vegetables. East Los Angeles Collegesubmitted a version of the self-efficacy for eating, asking and preparing fruits andvegetables survey in Spanish which is included following the English version.Who is the target audience?ChildrenAdditional informationThe surveys have been adapted from validated tools and should not bemodified. To choose the survey that is right for your program, look at the areasof self-efficacy that are targeted by each survey. Choose a survey with questionsthat most closely match your intervention objectives and one in which thestudents would most likely answer “Not Sure” or “I’m Sure I Cannot” before theintervention and “Very Sure” or “I am Sure I Can” after the intervention. Toanalyze the data, conduct a paired t-test on summary scores for the subscalesand all scales together.ReferencesBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Smith M, Lin L,Wang DT. Gimme 5 fruit and vegetables for fun and health: OutcomeEvaluation. Health Education & Behavior 2000; 27(1):96-111.Reynolds K, Yaroch A, et al. Testing mediating variables in a school-basednutrition intervention program. Health Psychol 2002; 21(1): 51-60.Self Efficacy 149

Self-Efficacy Survey – Eating, Asking, PreparingFVs (Reynolds, et al.)How sure are you that you can:Please check your answerNotSureI ThinkSoVerySure1. eat fruits I like (such as bananas or raisins) atbreakfast 1 2 3 2. eat vegetables I like (such as green peppers ortomatoes) at breakfast1 2 3 3. drink a glass of my favorite juice (such as orangejuice or apple juice) with my breakfast1 2 3 4. eat fruits I like (such as applesauce or fruit cocktail)at lunch1 2 3 5. eat vegetables I like (such as salad or a plainbaked potato) at lunch1 2 3 6. drink a glass of my favorite juice (such as grapejuice or V-8 juice) with my lunch1 2 3 7. eat fruits I like (such as apples or oranges) fordessert at dinner1 2 3 8. eat vegetables I like (such as corn or beans) atdinner 1 2 3 9. drink a glass of my favorite juice (such as tomatojuice or orange juice) with my dinner10. snack on fruits I like (such as grapes or bananas)instead of on foods like cake or cookies11. snack on vegetables I like (such as carrot or celerysticks) instead of on foods like potato or corn chips12. drink a glass of my favorite juice (such as applejuice or grape juice) with my snack13. ask my mom or dad to buy fruit for snacks1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 14. ask my mom or dad to fix my favorite vegetabledishes at dinner1 2 3 15. ask my mom or dad to keep 100% juice in therefrigerator1 2 3 16. help my mom or dad fix a fruit or vegetable snack 1 2 3 17. cook a vegetable (like corn-on-the-cob) for dinner1 2 3 Self Efficacy for Eating, Asking and Preparing 150

Exámen de Eficacia Propia–Comiendo,Preguntando, Preparando Frutas y VegetalesHow sure are you that you can:Que tan seguro/a estas que tu puedes:Please check your answerPor favor, marca tu respuesta con una NotSureNoestoySeguro/aI Think SoCreo quesíVerySureEstoySeguro/a1. Eat fruits I like at breakfast.Comer las frutas que te gustan en el desayuno.1 2 3 2. Eat vegetables I like at breakfast.Comer los vegetales que te gustan en el desayuno.1 2 3 3. Drink a glass of my favorite juice with my breakfast.Beber un vaso de tu jugo favorito con tu desayuno.1 2 3 4. Eat fruits I like at lunch.Comer las frutas que te gustan en el almuerzo.1 2 3 5. Eat vegetables I like at lunch.Comer los vegetales que te gustan en el almuerzo.1 2 3 6. Drink a glass of my favorite juice with my lunch.Beber un vaso de tu jugo favorito con tu almuerzo.1 2 3 7. Eat fruits I like for dessert at dinner.Comer las frutas que te gustan como postre después de la cena.1 2 3 8. Eat vegetables I like at dinner.Comer los vegetales que te gustan en la cena.1 2 3 9. Drink a glass of my favorite juice with my dinner.Beber un vaso de tu jugo favorito con tu cena.1 2 3 10. Snack on fruits I like.Comer bocadillos de las frutas que te gustan.1 2 3 11. Snack on vegetables I like instead of on foods like potato chips orcorn chips.Comer bocadillos de los vegetales que te gustan en lugar depapitas.1 2 3 12. Drink a glass of my favorite juice with my snack.Beber un vaso de tu jugo favorito con tu bocadillo.1 2 3 13. Ask my mom or dad to buy fruit for snacks1 2 3 Self Efficacy for Eating, Asking and Preparing (Spanish) 151

How sure are you that you can:Que tan seguro/a estas que tu puedes:Please check your answerPor favor, marca tu respuesta con una NotSureNoestoySeguro/aI Think SoCreo quesíVerySureEstoySeguro/aPedir a mi mamá o papá a comprar fruita a comer comobocadillos14. Ask my mom or dad to fix my favorite vegetable dishes at dinnerPedir a mi mamá o papá a preparer mi vegetal favorite para lacena15. Ask my mom or dad to keep 100% juice in the refrigeratorPedir a mi mamá o papá que mantenga 100% jugo en larefrigeradora1 2 3 1 2 3 16. Help my mom or dad fix a fruit or vegetable snack.Ayuda a tu mamá o papá a preparer bocadillos de fruta o1 2 3 vegetales.17. Cook a vegetable (like corn-on-the-cob) for dinnerCocinar un vegetal para la cena 1 2 3 Self Efficacy for Eating, Asking and Preparing (Spanish) 152

Self-Efficacy Survey - Eating FVs (Baranowski, et al.)I think I can…1. For breakfast, I think I can…A. drink a glass of my favorite juiceB. add fruit to my cereal2. For lunch at school, I think I can…IdisagreeverymuchPlease check your answerI disagree I am not I agree aa little sure littleI agreeverymuch1 2 3 4 5 1 2 3 4 5 I I disagreedisagree a littleverymuchI am notsureI agree alittleI agreeverymuchA. eat a vegetable that’s served 1 2 3 4 5 B. eat a fruit that’s served 1 2 3 4 5 I I disagree I am not I agree a I agree3. For lunch at home I think I can…disagree a little sure little veryverymuchmuchA. Eat carrot or celery sticks instead ofchipsB. Eat my favorite fruit instead of myusual dessert4. For a snack I think I can choose…A. my favorite fruit instead of myfavorite cookieB. my favorite fruit instead of myfavorite candy barC. my favorite raw vegetable with dipinstead of my favorite cookieD. my favorite raw vegetable with dipinstead of my favorite candy barE. my favorite raw vegetable with dipinstead of chips5. For dinner I think I can….1 2 3 4 5 1 2 3 4 5 I I disagreedisagree a littleverymuchI am notsureI agree alittleI agreeverymuch1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 IdisagreeverymuchI disagreea littleI am notsureI agree alittleI agreeverymuchA. eat a big serving of vegetables 1 2 3 4 5 B. eat my favorite fruit instead of myusual dessert1 2 3 4 5 Self Efficacy for Eating 153

Self-Efficacy Survey - Asking and Shopping for FVs(Baranowski, et al.)How sure are you that you can:1. write my favorite fruit or vegetable on thefamily’s shopping list2. ask someone in my family to buy my favoritefruit or vegetable3. go shopping with my family for my favoritefruit or vegetable4. pick out my favorite fruit or vegetable at thestore and put it in the shopping basket5. ask someone in my family to make myfavorite vegetable dish for dinner6. ask someone in my family to serve myfavorite fruit at dinner7. ask someone in my family to have fruits andfruit juices out where I can reach them8. ask someone in my family to have vegetablescut up out where I can reach themIdisagreeverymuchPlease check your answerIdisagreea littleI am notsureI agree alittleI agreeverymuch1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Self-efficacy for Asking and Shopping 154

PHYSICAL ACTIVITY TOOLSPhysical Activity Surveys for Adults 155

Physical Activity Surveys for AdultsTarget behaviorPhysical activityWhat is being measured?The first survey is part of Module 4 of the CDC’s Behavior Risk FactorSurveillance System. It is a 7-item survey designed to detect changes inmoderate to vigorous activity. Remington and colleagues provide background onthe BRFSS.The second survey, the 7-day Physical Activity Recall (PAR), is astructured interview that measures a person’s time spent engaging in physicalactivity over a seven day period. It covers different levels of physical activityintensity such as aerobic exercise, work-related activities, gardening, walking,recreation, and leisure-time activities. The PAR, developed by Sallis, et al.(1985) for the Stanford Five-City Project, has been used with adultpopulations for several projects including the San Diego Family Health Projectand Project GRAD. It appears to be most appropriate for men between theages of 18 and 69, coed college students, male and female 11 th gradestudents; and is marginally suitable for 8 th grade students. A study by Taylor,et al. (1984) using a sample of men between the ages of 34 and 69 showedsignificant correlations between a weekend activity log and two PAR activities(moderate = 0.70; hard/very hard = 0.66). With a population of men betweenthe ages of 18 and 31, Dishman et al. (1988) obtained a correlation of 0.83between the PAR and a past year activity log. In the same study, among asample of co-ed college students the PAR also correlated with a 7-dayactivity log (0 .71).Studies also suggest that the PAR performs better in measuringphysical activity in the very hard intensity categories. Sallis, et al. (1993)examined the association between the PAR’s very hard activity level withheart rate monitoring time periods among 5 th , 8 th , and 11th grade students.Significant correlations were highest at the 11 th grade level (0.72) andmoderately high among students in the eighth grade (0.45). Hayden-Wadeand colleagues (2003) later validated this instrument against TriTrac-R3Daccelerometer data. The highest correlations were obtained betweenaccelerometer data and the PAR at the very hard physical activity level,administered by telephone (0.78) or in person (0.74). Full citations for otherPAR validation studies can be found in Sarkin, et al. (1997).Who is the target audience?First two surveys: AdultsPhysical Activity Surveys for Adults 156

PAR: Men ages 18 to 69; college students, 8 th and 11 th gradestudents.Additional informationThe surveys have been validated and should not be modified. Youmay want to use these surveys if your intervention targets increasing physicalactivity among adults and you expect them to report engaging in more ofthese physical activities after the intervention. The PAR is administered as aninterview following a standard format; complete instructions can be found inthe Project GRAD Seven-Day PAR Interviewers’ Manual athttp://www.drjamessallis.sdsu.edu/sevendayparprotocol.pdf.ReferencesFirst survey:Behavior Risk Factor Surveillance System. (2002) Module 4 Physical Activity.[Online] Available: http://www.cdc.gov/brfss/questionnaires/pdfques/2002brfss.pdf.Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC.Design, characteristics and usefulness of state-based Behavioral Risk FactorSurveillance: 1981-1987. Public Health Rep. 1988; 103: 366-375PAR:Dishman, RK and Steinhardt, M. Reliability and concurrent validity for a 7-dayrecall of physical activity in college students. Med Sci Sports Exerc 1998;20:14-25.Hayden-Wade HA, Coleman KJ et al. Validation of the telephone and in-personinterview versions of the 7-day PAR. Med Sci Sports Exerc 2003; 35(5): 801-809.Sallis JF, Haskell W, and Wood, P et al. Physical activity assessmentmethodology in the Five-City Project. Am. J. Epidemiol 1985; 121: 91-106.Sallis JF, Buono MJ, Roby JJ, Micale FG, and Nelson, JA. Seven-day recalland other physical activity self reports in children and adolescents. Med SciSports Exerc 1993; 25:99-108.Sarkin J, Campbell J, and Gros L, et al. Project Grad Seven-Day PhysicalActivity Recall Interviewers’ Manual. Med Sci Sports Exerc 1997; 29(Suppl.):S89-103. [online]. Available:http://www.drjamessallis.sdsu.edu/sevendayparprotocol.pdf.Taylor CB, Coffey T, Berra K, Iaffaldano R, Casey K, and Haskell WL.Seven-day activity and self-report compared to a direct measure of physicalactivity. Am. J. Epidemiol 1978; 120:818-824.Physical Activity Surveys for Adults 157

Physical Activity Survey (BRFSS)Please check your answer1. When you are at work, which of the following best describe what you do?Would you say:1 Mostly sitting or standing2 Mostly walking or3 Mostly heavy labor or physically demanding work4 Don’t know/Not sure5 RefusedWe are interested in two types of physical activity: VIGOROUS andMODERATE.VIGOROUS activities cause large increases in breathing or heart rate whileMODERATE activities cause small increases in breathing or heart rate.2. Now, thinking about the moderate physical activities you do in a usualweek when you are not working, do you do MODERATE activities for atleast 10 minutes at a time, such as brisk walking, bicycling, vacuuming,gardening, or anything else that causes small increases in breathing orheart rate?1 Yes2 No (Go to Question 5)3 Don’t know/Not sure (Go to Question 5)3. How many days per week do you do these moderate activities for at least10 minutes at a time?___ ___ Days per week4. On days when you do moderate activities for at least 10 minutes at atime, how much total time per day do you spend doing these activities?___ : ___ Hours and minutes per day5. Now thinking about the vigorous physical activities you do in a usualweek when you are not working, do you do VIGOROUS for at least 10minutes at a time, such as running, aerobics, heavy yard work, or anythingelse that causes large increases in breathing or heart rate?1 Yes2 No (Stop)3 Don’t know/Not sure (Stop)6. How many days per week do you do these vigorous activities for at least10 minutes at a time?___ ___ Days per week7. On days when you do moderate activities for at least 10 minutes at atime, how much total time per day do you spend doing these activities?____________ Hours and minutes per dayPA BRFSS 158

7-Day Physical Activity Recall (Sallis, et al.)Seven Day Physical Activity Recall 159

Seven Day Physical Activity Recall 160

Physical Activity Surveys for Children and TeensTarget behaviorPhysical activityWhat is being measured?The YRBS survey questions measure physical activity behavior, not afactor. The questions were taken from the physical activity section of the YouthRisk Behavior Survey (YRBS), which has been used to assess physical activityamong high school students.Who is the target audience?YRBS Survey: High school students 9 th – 12 th grade, roughly between ages 14and 18Additional informationYou may want to use these questions if your intervention targets physicalactivity among adolescents or teens and you expect them to report engaging inmore of these physical activities after the intervention than they do before theintervention.ReferencesYouth Risk Behavior Surveillance System 2003 State and Local Standard HighSchool Questionnaire.http://www.cdc.gov/nccdphp/dash/yrbs/2003/questionnaire.htmPA Children & Teens 161

Physical Activity Survey (YRBS)Please check your answer1. On how many of the past 7 days did you exercise or participate inphysical activity for at least 20 minutes that made you sweat andbreathe hard, such as basketball, soccer, running, swimming laps,fast bicycling, fast dancing, or similar aerobic activities?1 0 days2 1 day3 2 days4 3 days5 4 days6 5 days7 6 days8 7 days2. On how many of the past 7 days did you participate in physicalactivity for at least 30 minutes that did not make you sweat or breathehard, such as fast walking, slow bicycling, skating, pushing a lawnmower, or mopping floors?1 0 days2 1 day3 2 days4 3 days5 4 days6 5 days7 6 days8 7 days3. On how many of the past 7 days did you do exercises tostrengthen or tone your muscles, such as push-ups, sit-ups, orweight lifting?1 0 days2 1 day3 2 days4 3 days5 4 days6 5 days7 6 days8 7 daysPA YRBS 162

4. On an average school day, how many hours do you watch TV?1 I do not watch TV on an average school day2 Less than 1 hour per day3 1 hour per day4 2 hours per day5 3 hours per day6 4 hours per day7 5 or more hours per day5. In an average week when you are in school, on how many days doyou go to physical education (PE) classes?1 0 days2 1 day3 2 days4 3 days5 4 days6 5 days6. During an average physical education (PE) class, how manyminutes do you spend actually exercising or playing sports?1 I do not take PE2 Less than 10 minutes3 10 to 20 minutes4 21 to 30 minutes5 31 to 40 minutes6 41 to 50 minutes7 51 to 60 minutes8 More than 60 minutes7. During the past 12 months, on how many sports teams did youplay?(Include any teams run by your school or community groups.)1 0 teams2 1 team3 2 teams4 3 or more teamsPA YRBS 163

Physical Activity Preferences for Children and AdultsTarget behaviorIncreasing physical activityWhat is being measured?The factor of physical activity preferences is strongly linked to physicalactivity behavior. The survey that follows is comprised of a sample list of physicalactivities that includes both examples that children probably are familiar with andothers that may be new to children.Who is the target audience?Children and adults: The survey was adapted from an instrumentdeveloped by Sherwood, et al. (2003).Additional informationThe list of activities may be modified to include those targeted by aparticular intervention. The Network recommends that LIAs list several activitiesto identify some that the target audience does not like or with which it isunfamiliar. The choices that are unfamiliar or are disliked can be used as targetsfor an intervention.ReferencesSherwood N, Story M, Neumark-Sztainer D, Adkins S, Davis M. Developmentand implementation of a visual card sorting technique for assessing food andactivity preferences and patterns in African American girls. J of the AmericanDietetic Association 2003; 103: 1473-1479.PA Preferences 164

Physical Activity Preferences Survey (Sherwood,et al.)How much do you like thesephysical activities? Please check your answerI like this alotI like this alittleI do notlike thisI don’t knowwhat this isWater play (swimming pool, lake) Arts and crafts Computer games, video games Bicycle Games such as chase, tag, hopscotch Listen to music, plan an instrument Jump rope Skateboarding, skating, rollerblading Climb on playground equipment Watch T.V., videos Play board games Outdoor play, climb trees, hide & seek Swim laps Running Talk on the phone Dancing Indoor chores: mopping, sweeping,vacuuming Outdoor chores: mowing, raking,gardening Football Exercise like push-ups, sit-ups andjumping jacks Baseball/ softball Basketball Weight lifting, strength training Racket sports: badminton, tennis Yoga Hiking Dance Martial arts Gymnastics Homework, reading Volleyball Soccer Are there other physical activities that you really like? Yes what kind? ____________________________________________Physical Activity Preferences 165

Self Efficacy for Physical Activity Survey for AdultsTarget behaviorIncrease physical activity.What is being measured?Below is a list of things people might do while trying to increase orcontinue regular exercise. The survey includes questions about exercises likerunning, swimming, brisk walking, bicycle riding, or aerobics classes.Who is the target audience?AdultsAdditional informationThe survey has been validated and should not be modified. You want tobe able to show that the intervention produced a change in self efficacy forincreasing physical activity. If your intervention is focused on increasing selfefficacy for physical activity among adults, you may want to use this survey.Choose this survey if you expect the participants to answer “I Know I Cannot” tomost questions before the intervention and “I Know I Can” to most questions afterthe intervention.ReferencesSallis JF, Pinski RB, Grossman RM, Patterson TL and Nader PR. Thedevelopment of self-efficacy scales for health-related diet and exercisebehaviors. Health Education Research 1988; 3, 283-292Self-efficacy for PA - adults 166

Self-Efficacy for Physical Activity Survey (Sallis,et al.)Whether you exercise or not, pleaserate how confident you are that youcould really motivate yourself to dothings like these consistently, for atleast six months.1. Get up early, even on weekends, toexercise.2. Stick to your exercise program aftera long, tiring day at work.3. Exercise even though you arefeeling depressed.4. Set aside time for a physical activityprogram; that is, walking, joggingswimming, biking, or other continuousactivities for at least 30 minutes, 3times per week5. Continue to exercise with otherseven though they seem too fast or tooslow for you.6. Stick to your exercise program whenundergoing a stressful life change(e.g., divorce, death in the family,moving).I KnowICannotMaybe I Can I Know I Can DoesNotApply 7. Attend a party only after exercising. 8. Stick to your exercise program whenyour family is demanding more timefrom you. 9. Stick to your exercise program whenyou have household chores to do.10. Stick to your exercise programeven when you have excessivedemands at work.11. Stick to your exercise programwhen social obligations are very timeconsuming.12. Read or study less in order toexercise more. Self Efficacy for Physical Activity 167

Social Support for Physical Activity Survey for AdultsTarget behaviorIncreasing physical activityWhat is being measured?It is not easy to change behavior. One factor that is most likely to effectchange in behavior is support from peers, family and friends. The followingsurvey measures support from family and friends for increasing physical activity.Who is the target audience?AdultsAdditional informationThis survey has been validated and should not be modified. You want tobe able to show that the intervention produced a change in social support forphysical activity. If your intervention is focused on helping adults learn how toincrease their social support, you may want to use this survey. Choose thissurvey if you expect the participant to answer 1 (None) to most positive questionsabout support for physical activity before the intervention and 5 (Very Often) tomost positive questions after the intervention.ReferencesSallis JF, Grossman RM, Pinski RB, Patterson TL, and Nader PR. TheDevelopment of Scales to Measure Social Support For Diet and ExerciseBehaviors. Preventive Medicine 1987; 16, 825-836.Social Support for PA 168

Social Support From Family & Friends forPhysical Activity Survey (Sallis, et al.)Please write one number from the following rating scale in each space1 2 3 4 5 8none rarely A fewtimesoften Very often Does notapplyDuring the past three months, my family (or members of myhousehold) or friendsFamilyFriends1 exercised with me. A_____ B_____2 offered to exercise with me. A_____ B_____3 gave me helpful reminders to exercise ("Are you going toexercise tonight?”).4 gave me encouragement to stick with my exerciseprogram.A_____ B_____A_____ B_____5 changed their schedule so we could exercise together. A_____ B_____6 discussed exercise with me. A_____ B_____7 complained about the time I spend exercising. A_____ B_____8 criticized me or made fun of me for exercising. A_____ B_____9 gave me rewards for exercising (bought me somethingor gave me something I like).A_____ B_____10 planned for exercise on recreational outings. A_____ B_____11 helped plan activities around my exercise. A_____ B_____12 asked me for ideas on how they can get more exercise. A_____ B_____13 talked about how much they like to exercise. A_____ B_____Social Support for PA 169

Demographic InformationRace and ethnicity may be collected by means of a two-part question. The firstconcerns ethnicity, i.e., Hispanic or not Hispanic, and the second concerns race.The US Census Bureau defines ethnicity as: the heritage, nationality group,lineage, or country of birth of a person, a person’s parents, or ancestors beforearrival to the US. http://www.census.gov/Press-Release/www/2001/raceqandas.html. Ethnicity is defined as either Hispanic orLatino or Not Hispanic or Latino.Hispanic or Latino refers to a person of Cuban, Mexican, Puerto Rican, South orCentral American, or other Spanish culture or origin regardless of race.The Office of Management and Budget distinguishes five racial groupshttp://www.whitehouse.gov/omb/inforeg/re_guidance2000update.pdf . They include:1. American Indian or Alaska Native: a person has origins of any of theoriginal people of North or South America who maintain tribal affiliation2. Asian: a person has origins of any of the original people of the FarEast, Southeast Asia, or the Indian Subcontinent3. Black or African American: a person has origins in any of the blackracial groups of Africa4. Native Hawaiian or Other Pacific Islander: a person has origins of anyof the original people of Hawaii, Guam, Samoa, or other Pacific Island5. White: a person has origins of any of the original people of Europe,Middle East, or North Africa1. Are you Hispanic or Latino? Yes No2. What is your race? (Select one or more responses.) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White