1 Survey

Appendix A

A.2.1.a.3–1
OMB #: 0925-xxxx
Expiration Date: xx/xxxx

3-Day Dietary Checklist

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

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Appendix A
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A.2.1.a–2

Draft

National Children's Study

3-Day Food Checklist
Instructions
Fill out one Food Checklist throughout the day on the three days marked below:
Sunday, Monday, Tuesday

Thursday, Friday, Saturday

Each Food Checklist asks about some but NOT all of the foods you eat.
Each Food Checklist asks about how many different times you eat a food each day, NOT how many
pieces or servings you eat each time.

Complete each Food Checklist by marking

each time you eat a food on that day.

Use only black or blue pen to mark your foods. If you make a mistake, mark

on the wrong answer.

How to Complete this Form
a box for every food you eat at
Mark
a different meal or snack.

Record mixtures (sandwiches, casseroles,
salads, pasta and stir-fry dishes) by checking
each food in the mixture.

Example:

Example:

"I drank 1/2 glass of whole milk for
breakfast and 1 glass for a snack in the
afternoon."

"I ate a turkey sandwich (2 slices of white
bread, lettuce, tomato, and mayonnaise)."

Milk whole

Bread, white
Turkey
Lettuce
Tomatoes

Do NOT count the number of pieces or
servings of the same food you eat at a
meal or snack.

Example:

Example:

"I ate a lettuce salad with onion, cucumber,
and carrots."

"I ate 2 pieces of cornbread for lunch."
Corn cereal, cornbread,
or corn tortilla

Lettuce
Onion
Cucumber
Carrots

Example:
"I ate lasagna with tomato sauce and
ground beef."
Pasta noodles
Beef
Tomatoes

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A.2.1.a–3

Draft

Day 1
1. Please enter today's DATE
/

mm

/

dd

Beverages

2 0

Apple juice

yyyy

Grape juice
Orange juice

2. What day is TODAY?

Wine

Sunday

Beer

Monday

Coffee, regular

Tuesday

Soda or pop
Thursday

Green Tea - hot or iced

Friday

Water, tap

Saturday

Water, filtered
Water, bottled

3. Mark a box for each time you eat any of
the foods listed.

Dairy - include flavored milks such as chocolate milk

Cereal, Breads and Grains

Milk whole

Corn cereal, corn bread,
or corn tortilla

Milk 2%

Oatmeal or oat cereal

Milk 1%

White rice or rice cereal

Milk skim
Other milk -

Pasta noodles
soy, rice, or other milk

Bread, white

Yogurt, all kinds

Bread, whole wheat

Cheese, all kinds

Barley
Other grains

2

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A.2.1.a–4

Draft

Day 1
Fruits

Sweets

Apple with peel

Ice cream

Banana

Cookies

Cantaloupe

Sugar

Grapes

Hard candy

Orange

Other sweets

Peaches

Eggs, Fish, Poultry and Meat

Strawberries

Eggs

Watermelon

Fish or shellfish

Other fruits

Chicken

Turkey

Vegetables

Beef

Beans, green

Pork

Broccoli

Venison, pheasant, duck,
or other meats

Carrots
Cucumber

Peanut Butter and Nuts

Corn
French fries

Peanut butter

Lettuce

Nuts - all kinds

Onion

4. Think about the fruits and vegetables you
ate today. About how many of those foods
were labeled "organic"?

Peas

Potatoes - no peel

All

Potatoes - with peel

Most

Tomatoes

Some

Other vegetables

None
Don't Know

3

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A.2.1.a–5

Draft

Day 2
Beverages

Check that you answered Question 4
for the previous day.

Apple juice

1. Please enter today's DATE
/

mm

/

dd

Grape juice
Orange juice

2 0

Wine

yyyy

Beer

2. What day is TODAY?

Coffee, regular

Sunday

Soda or pop

Monday

Green Tea - hot or iced

Tuesday

Water, tap

Thursday

Water, filtered

Friday

Water, bottled

Saturday
3. Mark a box for each time you eat any of
the foods listed.

Cereal, Breads and Grains
Corn cereal, corn bread,
or corn tortilla

Dairy - include flavored milks such as chocolate milk

Oatmeal or oat cereal

Milk whole

White rice or rice cereal

Milk 2%

Pasta noodles

Milk 1%

Bread, white

Milk skim
Other milk -

Bread, whole wheat
soy, rice, or other milk

Barley

Yogurt, all kinds

Other grains

Cheese, all kinds

4

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A.2.1.a–6

Draft

Day 2
Fruits

Sweets

Apple with peel

Ice cream

Banana

Cookies

Cantaloupe

Sugar

Grapes

Hard candy

Orange

Other sweets

Peaches

Eggs, Fish, Poultry and Meat

Strawberries

Eggs

Watermelon

Fish or shellfish

Other fruits

Chicken
Turkey

Vegetables

Beef

Beans, green

Pork

Broccoli

Venison, pheasant, duck,
or other meats

Carrots
Cucumber
Corn

Peanut Butter and Nuts

French fries

Peanut butter

Lettuce

Nuts - all kinds

Onion

4. Think about the fruits and vegetables you
ate today. About how many of those foods
were labeled "organic"?

Peas
Potatoes - no peel

All

Potatoes - with peel

Most

Tomatoes

Some

Other vegetables

None
Don't Know

5

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A.2.1.a–7

Draft

Day 3
Beverages

Check that you answered Question 4
for the previous day.

Apple juice

1. Please enter today's DATE
/

mm

/

dd

Grape juice
Orange juice

2 0

Wine

yyyy

Beer

2. What day is TODAY?

Coffee, regular

Sunday

Soda or pop

Monday

Green Tea - hot or iced

Tuesday

Water, tap

Thursday

Water, filtered

Friday

Water, bottled

Saturday
3. Mark a box for each time you eat any of
the foods listed.

Cereal, Breads and Grains
Corn cereal, corn bread,
or corn tortilla

Dairy - include flavored milks such as chocolate milk

Oatmeal or oat cereal

Milk whole

White rice or rice cereal

Milk 2%

Pasta noodles

Milk 1%

Bread, white

Milk skim
Other milk -

Bread, whole wheat
soy, rice, or other milk

Barley

Yogurt, all kinds

Other grains

Cheese, all kinds

6

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A.2.1.a–8

Draft

Day 3
Fruits

Sweets

Apple with peel

Ice cream

Banana

Cookies

Cantaloupe

Sugar

Grapes

Hard candy

Orange

Other sweets

Peaches

Eggs, Fish, Poultry and Meat

Strawberries

Eggs

Watermelon

Fish or shellfish

Other fruits

Chicken
Turkey

Vegetables

Beef

Beans, green

Pork

Broccoli
Carrots

Venison, pheasant, duck,
or other meats

Cucumber

Peanut Butter and Nuts

Corn

Peanut butter

French fries

Nuts - all kinds

Lettuce

4. Think about the fruits and vegetables you
ate today. About how many of those foods
were labeled "organic"?

Onion
Peas

All

Potatoes - no peel

Most

Potatoes - with peel

Some

Tomatoes

None

Other vegetables

Don't Know
To finish, go to question 5 on the next page.

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Appendix A
A.2.1.a–9

Draft

8. Did you have any difficulty understanding
how to fill out the Food Checklist?
If so, please explain.

Check that you answered Question 4
for the previous day.
5. In the past month, how often did you wash
your hands before preparing food for your
family?
Always
Usually
Sometimes
Seldom
6. In the past month, how often did you wash
the cutting board or counter before
preparing food on it?
Always
Usually
Sometimes
Seldom
7. In the past month, how often did you wash
or rinse fresh fruits and vegetables at least
20 seconds and drain 2 minutes before
preparing them for your family?
Always
Usually
Sometimes
Seldom

Thank you very much for completing the 3-Day Food Checklist. All your answers are very
important to the study.
Public reporting burden for this collection of information is estimated to average (insert time) hours [or 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

8
Affix Label Here

Revised 7/7/08