Healthy Eating Active Living Youth Nutrition and Physical Activity Survey

Transcription

1 School Name: Today's Date: / / Healthy Eating Active Living Youth Nutrition and Physical Activity Survey Dear Student, Thank you for answering the following questions. We are interested in learning what you think about physical activity and nutrition. Please tell us your experiences and opinions. There are no right or wrong answers to any of these questions. Do not write your name on the questionnaire. All of your answers are anonymous. We hope that you will answer all of the questions, but you may skip any question if you choose to. We think it will take you about 30 minutes to finish this questionnaire. MARKING INSTRUCTIONS Use number 2 pencil only. Make dark marks that fill the circle completely. Erase cleanly any mark you wish to change. Make no stray marks. USE A NO. 2 PENCIL ONLY Correct Mark Incorrect Marks PLEASE DO NOT WRITE IN THIS AREA SERIAL #

2 Section 1: Nutrition Take a minute and think about what you did yesterday and answer the following questions. 1. Mark the circles for all of the places where you ate the following foods yesterday. If you did not eat a certain food item, just mark the first circle, "Did not eat". You can mark more than one circle for each food. Mark all that apply. terday, did you eat Did not eat Ate at school Ate at home Ate at some other place a. French fries or other fried potatoes b. Green salad c. Vegetables (Do not include green salads or fried potatoes) d. Fruit (Do not include fruit juice) e. Hot dogs, corn dogs, or hamburgers f. Pizza g. Fried chicken or chicken nuggets (Do not include other types of chicken) Remember, you can mark more than 1 circle for each item h. Nachos i. Candy of any kind j. Breakfast bars, sports bars, granola bars, or other similar kinds of bars k. Ice cream or frozen yogurt l. Other sweets like cake, cookies, donuts, pop-tarts, brownies, sweet rolls, pan dulce, etc. m. Chips such as tortilla chips, potato chips, corn chips, Cheetos, cheese puffs, pork rinds, etc. (Do not include baked chips) n. Baked chips, pretzels, crackers, or similar snacks Page 2

3 2. Mark the circles for all of the places where you drank the following beverages yesterday. If you did not drink a certain item, just mark the first circle, "Did not drink". You can mark more than one circle for each beverage. Mark all that apply. terday, did you drink a. Milk b. Diet drinks, such as diet soda, diet tea, etc. c. Regular soda or soft drinks d. Sports drinks such as Gatorade and Powerade e. Energy drinks, such as Red Bull, Amp, Rockstar, etc. f. 100% fruit juice, such as orange juice, apple juice or grape juice (Do not include fruit-flavored drinks, Sunny Delight, aguas frescas, sports drinks, etc.) g. Sweetened juice drinks or other sweetened drinks, such as Sunny Delight, Icees, sweetened coffee or tea, Vitamin Water, aguas frescas, Koolaid, etc. Did not drink Drank at school Drank at home Drank at some other place h. Water, out of the tap, from a water fountain or from a bottle (or any other unsweetened water) 3. How many servings of the following items did you eat or drink yesterday? (A serving is whatever it means to you). Mark only one answer for each item. 4 or more ne serving servings servings servings a. French fries or other fried potatoes b. Green salad c. Vegetables, any kind (Do not include green salads or fried potatoes) d. 100% fruit juice e. Fruit, any kind (Do not include fruit juice) 4. Did you eat breakfast today?, I ate breakfast today, but I had a snack this morning, I ate nothing this morning 5. In the last 7 days, how many times did you eat or drink anything from a fast food restaurant? (For example, McDonald's, Pizza Hut, KFC, Taco Bell, etc.) 0 times 1 time 2-3 times 4-6 times 7-10 times More than 10 times Page 3 PLEASE DO NOT WRITE IN THIS AREA SERIAL #

4 6. How often are these statements true in your opinion? Always or almost always Often Sometimes Never or almost never a. I eat dinner at home with my family b. In my neighborhood it is easy to find a place to buy fruits or vegetables c. In my neighborhood it is easy to find a place to buy healthy snacks d. In my neighborhood it is easy to find a place to buy candy, soda and other sweets e. It is easy to buy healthy foods at fast food or other affordable restaurants in my neighborhood f. Healthy foods taste good g. Healthy foods cost too much Section 2: School Food 7. Did you eat anything while you were at school yesterday? 8. Did you eat the school breakfast yesterday? 9. Did you eat the school lunch yesterday? 10. Mark the circles for all of the places from which you bought food or drinks yesterday at school. You can mark more than one circle for each item., Mark all that apply. terday at school, did you buy food or drinks from a a. Vending machine at school b. Snack bar, cart, or store at school c. Other sale or fundraiser at school d. Friend or other student (not as part of a school sale or fundraiser) at school, bought during school 11. Think about this school year, when you answer the following question: bought before or after school About how often are you given candy, cookies, cake or similar foods in class as part of a celebration or as a reward?, did not buy or not available Once a week or more A few times a month About once a month A few times this school year Never or almost never Page 4

5 12. How important is it to you to be able to buy the following at school? a. Chips, such as potato chips, cheese puffs, corn chips, pork rinds, etc. (Do not include baked chips) b. Low fat snacks such as baked chips, pretzels, crackers, etc. Very important Important t very important t at all important c. French fries d. Regular soda or other sweetened beverages e. Diet soda or other diet drinks f. Sports drinks g. Fresh fruit h. Green salad i. Other vegetables j. Candy or other sweets such as cookies, cakes, brownies, donuts, etc. k. Ice cream, frozen yogurt and other frozen desserts 13. How often are these statements true in your opinion? Always or almost always Often Sometimes Never or almost never a. The school lunch is healthy b. The school lunch tastes good c. The school breakfast is healthy d. The school breakfast tastes good e. The foods that are sold in places like vending machines, snack bars, carts or stores at my school are healthy f. The foods that are sold in places like vending machines, snack bars, carts or stores at my school taste good 14. During the past 12 months have you been in a class where you learned about how to make, grow or choose healthy foods?, and it was helpful, but it was not helpful Page 5 PLEASE DO NOT WRITE IN THIS AREA SERIAL #

6 Section 3: Physical activity You will see the words physical activity many times in this section. Physical activity is all kinds of movement and exercise. Some examples are dancing, walking, biking, doing sports, yard work, or playing active games with friends. You may do physical activities in a class, on a team, with a friend or your family, or by yourself. Take a minute and think about all of the activities you did during the past 7 days, then answer the questions below. 15. On how many of the past 7 days did you do the following types of physical activities? Mark only one answer for each item. a. Practice or play a team sport (like soccer, basketball, baseball, volleyball, tennis, football, hockey, etc.) even if you were practicing by yourself b. Play other ball games like kickball, handball, tetherball, wall ball, etc. c. Play other active games like capture the flag, tag, jump rope, etc. 0 days 1 day 2-3 days 4-5 days 6-7 days d. Walk quickly (for more than 10 minutes at a time) e. Run (for more than 10 minutes at a time) f. Practice martial arts, wrestling, boxing, kick boxing or a similar sport g. Do any kind of dance or gymnastics (include dance classes, Dance Dance Revolution, aerobics, etc.) h. Do yoga, Tai Chi, stretching, or similar exercise i. Skate, skateboard, or ride a scooter (include ice skating, rollerblading, etc. Do not include motorized scooters) j. Swim or do other water sports k. Ride a bicycle outdoors l. Lift weights, do sit-ups, push-ups, or other activities to build muscles m. Work out on other exercise equipment like a stationary bicycle, treadmill, or rock climbing wall Page 6

7 Think about the places where you have done physical activity not during school in the past week 16. When you were not in school, on how many of the past 7 days did you do the following? Mark only one answer for each item days day days days days a. Go to a park, outdoor skatepark, sports field or ball court where you were physically active outside, not during school b. Go to a recreation or youth center, gym, indoor skate park/rink, ball court, or other place where you were physically active indoors, not during school (Do not include your home or other people's homes) c. Use a biking, walking, or jogging trail, path or track, not during school d. Do any physical activity in the streets or yards of your neighborhood e. Take a class to do any type of exercise or physical activity (such as swimming, gymnastics, martial arts, exercise classes, etc. Do not include classes you did during school) f. Play on a sports team of any kind such as baseball, soccer, track, swim, wrestling, etc. (Do not include teams during school) g. Do any type of physical activity on school grounds but not during school hours w, think about the activities you did yesterday, both in school and outside of school. 17. terday, about how many minutes did you spend a. Exercising or doing a physical activity that made you sweat or breathe hard? (For example, basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar activities) 0 to 10 minutes About 10 to 20 minutes About 20 to 30 minutes About 30 to 60 minutes More than 60 minutes b. Participating in a physical activity that did not make you sweat or breathe hard? (For example, fast walking, slow bicycling, shooting baskets, skating, raking leaves, mopping floors, etc.) Page 7

8 18. terday about how many hours did you spend ne at all Less than 1 hour 1 to 2 hours 2 to 3 hours 3 to 4 hours More than 4 hours a. Playing video or computer games (including handheld games such as PSP, Gameboy, etc.) b. Watching movies or programs on a TV or computer (include TV shows, videos, DVDs, streaming video, video clips, etc.) c. Doing other things on the computer, like surfing the Internet, blogging, ing, instant messaging, text messaging, etc. (include time spent with hand-held computers) Section 4: Physical activity at school 19. terday during school but not in PE class, about how many minutes did you spend doing physical activities that made you sweat or breathe hard? 0 to 10 minutes About 10 to 20 minutes About 20 to 30 minutes More than 30 minutes 20. How did you get home after school yesterday? I walked I rode a bike, skateboard, skates, or scooter (not motorized) I rode in a car I rode the bus Other 21. How did you get to school today? I walked I rode a bike, skateboard, skates or scooter (not motorized) I rode in a car I rode the bus Other Page 8 PLEASE DO NOT WRITE IN THIS AREA SERIAL #

9 Think about this school year when you answer the following questions. 22. How often are you excused from, or do you miss, PE for the following reasons? I am excused from/miss PE... Always Sometimes Never a. For personal reasons (like health, cultural, religious reasons) b. Because I do other sports or exercise instead (like sports teams, cheerleading, dance, etc.) c. Because I am in the band or another type of club or class instead For another reason (explain) Keep thinking about this school year when you answer the questions below. 23. Are you taking PE at school this year?, all year, part of the year, not at all (skip to question 26) 24. How much do you like your PE classes at school? I like PE a lot I like PE a little bit I don't like PE very much I don't like PE at all 25. During PE class, how many minutes do you usually spend exercising or moving around (like when you stretch, run, dance, play soccer, etc.)? 0 to 10 minutes About 10 to 20 minutes About 20 to 30 minutes More than 30 minutes 26. terday, where did you go right after school? (Please mark only one answer) I went home (or to a friend or relative's house) I stayed at school for an after-school program I played on a sports team I went to another program or activity in my neighborhood I hung out in my neighborhood, around town, etc. Other 27. If you went to an after-school program yesterday, did you do any physical activity while you were there? I didn't go to an after-school program yesterday Page 9 Please continue on the next page

10 Section 5: Your Opinions About Nutrition And Physical Activity In Your Community 28. How often are the following statements true for you? Always or almost always Often Sometimes Never or almost never a. I enjoy being outdoors in my neighborhood b. I feel safe when I am outdoors in my neighborhood c. There are safe places in my neighborhood where I can walk or ride a bike d. My parents let me go outdoors in my neighborhood e. In my neighborhood, there are outdoor places to do the kinds of physical activities I like to do (places like parks, skate parks, sports fields, ball courts, etc.) f. In my neighborhood, there are indoor places to do the kinds of physical activities I like to do (places like youth and recreation centers, gyms, indoor skate parks and ball courts, etc.) g. I like to go to places in my neighborhood where they offer physical activities h. There are sports or other physical activities I would like to do but they cost too much i. It is easy for me to get to the places where I can do the physical activities that I like to do (such as classes, parks, sports team practice or games, etc.) j. I do physical activities with my family k. I do physical activities with my friends l. I have plenty of time to do the physical activities I like to do 29. During this school year have you a. Sold candy, cookies, fast food or similar foods as part of a school fundraiser (for example, bake sales) b. Sold books, magazines, cards, or wrapping paper as part of a school fundraiser c. Participated in a Walk- or Run-a-thon or other similar activity as part of a school fundraiser Page 10 PLEASE DO NOT WRITE IN THIS AREA SERIAL #

11 30. Do you participate in a group or program working to improve nutrition or physical activity at your school or in your community?, but I would like to, this doesn't interest me 31. Did you go to the doctor for a medical check-up (or physical exam) in the past year? (skip to question 34) 32. At your medical check-up (or physical exam), in the past year, did the doctor or nurse. I don't remember a. Measure your weight (weigh you) b. Measure your height 33. At your medical check-up (or physical exam), in the past year, did the doctor or nurse. a. Give you information about healthy eating, and it was helpful, but it was not helpful I don't remember b. Give you information about physical activity 34. How often do you see ads on TV for the following? Many times each day Most days Some Days Seldom or Never I don't watch TV a. Fruits or vegetables b. Sodas or other sweetened beverages c. Candy or other sweets d. Video or computer games e. Where or how to be physically active f. Where or how to get healthy food 35. How often do you hear radio ads or see billboards, posters, signs, etc. about the following? (Do not include TV commercials) Many times each day Most days Some Days Seldom or Never a. Fruits or vegetables b. Sodas or other sweetened beverages c. Candy or other sweets d. Video or computer games e. Where or how to be physically active f. Where or how to get healthy food Page 11 Just one more section to go!

12 Section 6: A little information about you 36. How do you describe yourself? (Mark all that apply) Asian American Indian or Alaska Native Hawaiian or Pacific Islander Black or African American Hispanic or Latino/Latina White or Caucasian Other 37. English is the language used in your home... All of the time Most of the time Some of the time Rarely 38. What grade are you in? 7th 9th 39. Are you... Female (Girl) (go to question 40) Male (Boy) (skip to question 41) 40. Girls, would you say that you are... Less physically active than most girls your age About as physically active as most girls your age More physically active than most girls your age Thank you, girls, you're finished! 41. Boys, would you say that you are... Less physically active than most boys your age About as physically active as most boys your age More physically active than most boys your age Thank you very much for completing this survey! Page 12 PLEASE DO NOT WRITE IN THIS AREA SERIAL # Printed in U.S.A. OpScan insight forms by Pearson NCS MM