1 Survey

Appendix A A.2.1.m–13

Version -1/16/2007 OMB # 0925-XXXX

EXP. DATE: XX/XX/XXXX

Source: Harvard FFQ; Project Viva Child FFQ Visits: 18 mo. Mode: Self-administered (Mail in) Estimated Time: 30 minutes		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

National Children’s Study

Child Food Questionnaire

18 Months

PROTECTION OF PRIVACY STATEMENT INSERTED HERE

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 30 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.

Please complete this questionnaire within 2 weeks and mail it in the large pre‑stamped envelope to:

LABEL FOR CLINICAL CENTER RETURN ADDRESS

G eneral Instructions

This questionnaire is about your 18 month-old child __________________. When we refer to “your child,” please respond with this 18-month old child in mind.

This questionnaire asks you about the foods your child has eaten in the past month.

Answer each question as best you can. Estimate if you are not sure. A guess is better than leaving a blank.

Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Do not fold, staple, or tear the pages.

P ut an X in the box next to your answer.

If you make any changes, cross out the incorrect answer and put an X in the box next to the correct answer. Also draw a circle around the correct answer.

BEFORE YOU BEGIN, PLEASE FILL IN TODAY’S DATE:

__ __/__ __/__ __

Month Day Year

A. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Fruits	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day
1. Orange
2. Grapefruit
3. Banana
4. Apple
5. Applesauce
6. Grapes
7. Peach or plum
8. Strawberries or other berries
9. Cantaloupe
10. Watermelon
11. Pears
12. Raisins or prunes

B. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Vegetables	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day
Corn
Peas
Tomatoes
Peppers (all kinds)
Carrots
Broccoli
Green beans
Spinach
Squash (orange or winter)
French fries, fried potatoes
Potatoes (baked, boiled or mashed)
Onion
Sweet potatoes or yams
Cabbage, coleslaw, or cauliflower
Cucumbers
Lettuce salad
Mixed vegetables
Baked beans or chili beans
Other dried beans, dried peas or lima beans

C. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Meat, fish, and other main dishes	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day
Pizza
Macaroni and cheese
Peanut butter
Hamburger, meatballs, or meatloaf
Beef—steak or roast
Pork—chops, roast, or ribs
Ham—baked or steak
Cold cuts (bologna, salami, ham)
Sausage
Bacon
Hot dogs
Fried chicken, chicken nuggets
Other chicken or turkey
Canned tuna
Fried fish, fish sticks
Other fish
Tofu or soy beans
Vegetable soup
Other soup

D. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Starches & grains	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day	5 or more times per day
Pasta
White rice
Brown Rice
White bread (slice, roll, or pita)
Dark bread (slice, roll, or pita)
Cornbread or tortilla
Oatmeal
Cereal (cold)
Donut, fried dough
Sweet roll or muffin
Pancake, waffle, or French toast
English muffin or bagel
Biscuit

E. Please check the box that best represents how often your child drank each of the beverages listed, on average, in the past month.

Drinks	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day	5 or more times per day
Milk, including chocolate milk
Hot chocolate
Apple juice
Grape juice
Orange juice
Pineapple juice
Other 100% juice
Fruit drinks (Hi-C, Kool-Aid, lemonade)
Soda (not sugar-free)
Soda (sugar-free)
Water

12. What kind of milk does your child usually drink?

Breast milk, breast fed Breast milk, expressed Formula made from cow’s milk Formula made from soy milk Whole milk 2% milk

1% milk Skim milk Soy milk Other My child does not drink milk

1 3. What kind of water does your child usually drink?

Tap water, not filtered

Tap water, filtered

Bottled water

F. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

O ther dairy & eggs	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day
Cheese, plain or in sandwiches
Cream cheese
Cottage cheese
Yogurt
Ice cream
Pudding
Whole eggs

G. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Oils and spreads	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day	5 or more times per day
Butter (not margarine)
Margarine (tub)
Margarine (stick)
Mayonnaise
Salad dressing

H. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.

Snacks and sweets	Never	Less than 1 time per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day	5 or more times per day
Chips (potato, corn or others)
Nuts
Crackers
Jell-O
Cookies or brownies
Cake or cupcakes
Pie
Chocolate candy
Other candy

I. Are there any other foods not mentioned above that your child eats at least once per week? Please write in the name of the food and check the box that best represents how often your child ate each food, on average, in the past month.

Other foods your child eats once per week	1 time per week	2–4 times per week	Nearly every day or every day	2 or more times per day	5 or more times per day
1. __________________________
2. __________________________
3. __________________________
4. __________________________
5. __________________________
6. __________________________
7. __________________________

J. In the past month, how often does your child eat fast foods away from home or as take out (French fries, egg rolls, fried chicken, shrimp, clams, etc.)?

Less than once per week

1 time per week

2 to 4 times per week

Nearly every day or every day

K . In the past month, did you always, usually, sometimes, or seldom:

	Always	Usually	Sometimes	Seldom
1. Wash your hands before preparing food for your family?
2. Wash the cutting board or counter before preparing food on it for your family?
3. Wash or rinse fresh fruits and vegetables 20 seconds and drain 2 minutes before preparing them for your family?

L . In the past month, did your child eat any of the following foods that contain raw eggs?

	Yes	No	Don’t know
Raw, homemade cookie or cake batter?
Homemade frosting with raw egg?
Caesar salad with raw egg?
Chocolate mousse with raw egg?
Homemade eggnog?
Homemade ice cream with raw egg?
Shakes with raw egg?

M. Where does your child eat, including breakfast, lunch, dinner, and snacks?
For each of these places, tell me if she eats in these places usually, sometimes,
or never.

	Usually	Sometimes	Never
Kitchen table or counter
High chair
Dining room table
Living room on a table or coffee table
On the carpet or floor anywhere in the house
Bedroom on a table or dresser
Garage
On a table or bench outside the house
Anywhere else he or she chooses

N. Which of the following supplements was your child given at least 3 days a week
during the past month? [MARK ALL THAT APPLY.]

F luoride

Iron

Vitamin D

Multi-vitamins

Other vitamins or supplements:
Specify ________________________________

None

O . Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS PILLS.]

Drops

Pills

Thank you very much for completing this questionnaire!

All of your answers are very important.

Please help us by looking at each page again to make sure that you:

Did not skip any pages and

Crossed out the wrong answer and circled the right answer if you made any changes.

Thank you for continuing to be part of
the National Children’s Study.

CFQ - 13