Attachment 2 Dietary Screener Module

Attachment 2.

Dietary Screener Module

OMB no. 0920-0237

Expires: 11/30/2009

Notice - Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m). Public reporting burden of this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0214).

1. These questions are about the different kinds of foods you ate or drank during the PAST MONTH, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

During the past month, how often did you eat HOT OR COLD CEREALS?

Show CARD 1.

2. When you ate cereal, what kinds did you usually eat?

Enter one or two types.

Add Help screen for interviewers.

Show CARD 2.

3. How often did you have MILK, either to drink or on cereal? Do NOT include small amounts of milk in coffee or tea.

Read if necessary: Do NOT include cream or soy milk. INCLUDE skim, no-fat, low-fat,

whole milk, buttermilk, and lactose-free milk. Also INCLUDE chocolate or other flavored milks.

Show CARD 3.

3a. What kind of milk did you usually use? (Pick the one you used most often).

Show CARD 4.

4. During the past month, how often did you drink regular, carbonated SODA OR SOFT DRINKS that contain sugar? Do NOT include diet soda.

Read if necessary: Do NOT include diet or sugar-free fruit drinks. Do NOT include juices or tea in

cans.

Show CARD 3.

5. How often did you drink 100% FRUIT JUICE, such as orange, mango, apple, and grape juices? Do NOT count fruit drinks.

Read if necessary: INCLUDE only 100% pure juices. Do NOT include fruit drinks with

added sugar, like cranberry cocktail, Hi-C, lemonade, Kool-aid, Gatorade, Tampico, and Sunny Delight.

Show CARD 3.

6. How often did you drink FRUIT-FLAVORED DRINKS with sugar (such as Kool-aid, Hi-C, lemonade, or cranberry cocktail)? Do NOT include diet drinks.

Read if necessary: INCLUDE Gatorade and other sports drinks with added sugar.

INCLUDE Tampico, Sunny Delight and Twister.

Do NOT include 100% fruit juices or soda. Do NOT include yogurt drinks or carbonated water.

Show CARD 3.

7. How often did you eat FRUIT? COUNT fresh, frozen or canned fruit. Do NOT count juices.

Show CARD 1.

8. How often did you eat a green leafy or lettuce SALAD, with or without other vegetables?

Read if necessary: INCLUDE spinach salads.

Show CARD 1.

9. How often did you eat FRENCH FRIES, home fries, or hash brown potatoes?

Show CARD 1.

10. How often did you eat OTHER POTATOES? COUNT baked potatoes, boiled potatoes, mashed potatoes and potato salad.

Show CARD 1.

11. How often did you eat COOKED DRIED BEANS, such as refried beans, baked beans, bean soup, and pork and beans? Do NOT include green beans.

Show CARD 1.

12. Not counting what you just told me about (lettuce salads, potatoes, cooked dried beans), and not counting rice, how often did you eat OTHER VEGETABLES?

Read if necessary: Examples of other vegetables include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli.

COUNT any form of the vegetable (raw, cooked, canned, or frozen).

Show CARD 1.

13. How often did you have TOMATO SAUCES such as spaghetti sauce or pizza with tomato sauce?

Show CARD 1.

14. How often did you have SALSA?

Show CARD 1.

15. How often did you eat PIZZA?

Show CARD 1.

16. Looking at this flashcard, how often did you eat RED MEAT?

Show CARD 5.

Show CARD 1.

17. Looking at this flashcard, how often did you eat PROCESSED MEAT?

Show CARD 6.

Read if necessary: INCLUDE processed poultry and red meat.

Show CARD 1.

18. How often did you eat any kind of CHEESE? Include cheese as a snack, cheese on burgers, sandwiches, and cheese mixed into such foods as lasagna, enchiladas, or casseroles.

Read if necessary: INCLUDE macaroni and cheese, quesadillas. Do NOT count cream cheese.

Show CARD 1.

19. How often did you eat WHOLE GRAIN BREAD including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do NOT include white bread.

Read if necessary: INCLUDE cracked wheat, multi-grain and bran breads.

Show CARD 1.

20. How often did you eat BROWN RICE or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do NOT include white rice.

Show CARD 1.

21. How often did you eat DOUGHNUTS, sweet rolls, Danish, muffins, or pop-tarts? Do NOT include sugar-free items.

Show CARD 1.

22. How often did you eat COOKIES, CAKE, PIE or BROWNIES? Do NOT include sugar-free kinds.

Read if necessary: INCLUDE low-fat kinds. Do NOT include ice cream and other frozen

desserts or candy.

Show CARD 1.

23. How often did you eat ICE CREAM or other FROZEN DESSERTS? Do NOT Include sugar-free kinds.

Read if necessary: INCLUDE low-fat kinds. INCLUDE frozen yogurt.

Show CARD 1.

24. How often did you eat CANDY? Include chocolate and other candy. Do not include dietetic candy.

Show CARD 1.

25. How often did you add SUGAR or HONEY to your tea or coffee?

Show CARD 7.

26. How often did you eat POPCORN? Include low-fat types.

Show CARD 1.

SHOW CARDS

CARD 1:

□	□	□	□	□	□	□	□	□	□
Never	1-3 times last month	1-2 times per week	3-4 times per week	5-6 times per week	1 time per day	2 times per day	3 times per day	4 times per day	5 or more times per day

CARD 2:

_____ Cooked cereals (such as oatmeal, cream of wheat, grits)

_____ All bran cereals (such as All Bran, Fiber One, 100% Bran, or Bran Buds)

_____ Cereals with some bran or fiber (such as Cheerios, Raisin Bran, Shredded Wheat, Total, Wheaties, 40% Bran Flakes, Granola, Grape Nuts, Muselix, etc.)

_____ Cereals with little bran or fiber (such as Corn Flakes, Honey Nut Cheerios, Froot Loops, Rice Krispies, Kix, Frosted Flakes, Special K, Cap’n Crunch, Blueberry Morning, Product 19, etc.)

_____ Other

CARD 3:

□	□	□	□	□	□	□	□	□	□
Never	1 time per month or less	2-3 times last month	1-2 times per week	3-4 times per week	5-6 times per week	1 time per day	2-3 times per day	4-5 times per day	6 or more times per day

CARD 4:

_____ WHOLE MILK

_____ 2% FAT

_____ 1% FAT

_____ NON-FAT, SKIM or ½% FAT

_____ Other

_____ Did not drink milk in past month

CARD 5:

RED MEAT

Include:

Beef, veal

Pork, bacon

Lamb

Hotdogs and cold cuts made with those meats

Mixtures with those meats, like sandwiches,

lasagna, stew, pizza…

Do NOT include:

Poultry

Fish or seafood

CARD 6:

PROCESSED MEAT

Include:

Cold cuts

Luncheon meats

Hotdogs

Bacon

Sausage

Mixtures with those meats, like sandwiches, soups, pizza, casseroles…

CARD 7:

□	□	□	□	□	□	□	□	□	□
Never	Less than 1 time per month	1-3 times last month	1 time per week	2-4 times per week	5-6 times per week	1 time per day	2-3 times per day	4-5 times per day	6 or more times per day