1 Survey

Pilot Study for the National Children's Study (NICHD)

A.2.1.n Infant 3-Day Checklist

Postnatal Activities - Mother and Children

OMB: 0925-0593

Please tell me about how much of the food fed to your baby today was commercial baby food?

Commercial baby foods are those sold especially for babies. Foods that are not commercial include fresh fruit, fruit juices other than those especially sold for babies, foods you prepare especially for baby, and table food.

Always commercial
baby food

Usually commercial baby food

Sometimes commercial baby food

Never commercial baby food

Not fed to baby
in past 7 days

a. Fruit and vegetable juice

c. Vegetables

d. Meat, chicken, combination dinners, etc

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Appendix A A.2.1.n–4

Source: EPA, NHANES, IFPS

Visits: 6, 12, and 18 Months

Mode: Self-administered

Estimated Time: 5 minutes

BAR CODE LABEL
OR SUBJECT ID HERE

|___|___|___|___|___|___|___|___|

National Children’s Study

Infant 3-Day Food Checklist

6, 12, and 18 Months

Instructions!

This booklet contains 3 Food Checklists and Instructions.

Fill out one Food Checklist throughout the day on the next:

[PUT LABEL HERE WITH DAYS]

[EITHER TH, F, SA OR SU, M, TU]

Each Food Checklist asks about some (but NOT all) of the foods your baby eats.

Each Food Checklist asks about how many different times your baby eats a food each day (NOT how many pieces or servings your baby eats each time).

Complete the Checklist each day by checking a box each time your baby eats a food on that day.

If your baby is regularly cared for by someone else, it is very important that you ask your child-care provider to fill out the Checklist while caring for your baby.

U se only a black ball-point pen (not red ink or felt tip) to mark your foods. If you make a mistake, cross out the incorrect answer.

How to Record Foods

Check (_) a box for every food your baby eats at a different meal or snack.

Example: My baby drank a bottle of formula made from cow’s milk for breakfast, half a bottle for a mid-morning snack, a bottle for lunch, half of a small bottle in the afternoon, formula from a cup at dinner and a bottle at night.



Cow’s milk formula

Do NOT count the number of pieces or servings of the same food your baby eats at a meal or snack.

Example: My baby ate two animal crackers for a snack.



Animal crackers

Record pureed or chopped baby food you make or commercial baby food you buy at the store by checking the kind of food your baby ate.

Example: My baby ate one half jar of pureed carrots at lunch and the rest of the jar at dinner.



Carrots

Record commercial baby food combination dinners, such as a Turkey and Rice Dinner or a Spaghetti Dinner, as a combination dinner under Meat, Fish, Eggs and Other Main Dishes.

Example: My baby ate a half jar of vegetable stew for babies at lunch and another half jar for dinner.



Combination dinners (commercial baby food)

Record mixtures (casseroles, pasta, and beans and rice dishes) by checking each food in the mixture.

Example: My baby ate a few spoonfuls of macaroni and cheese for dinner.



Pasta noodles



Cheese



Cow’s milk

Please enter today’s DATE ____ / ___ / ____ (month/day/year)

What day is TODAY? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Now fill in the foods your baby eats today in the boxes below.

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Please enter today’s DATE ____ / ___ / ____ (month/day/year)

What day is TODAY? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Now fill in the foods your baby eats today in the boxes below.

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Please enter today’s DATE ____ / ___ / ____ (month/day/year)

What day is TODAY? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Now fill in the foods your baby eats today in the boxes below.

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Think about the fruits and vegetables and baby foods you fed your baby today. How many of those foods were labeled “organic”?

All

Some

Most

None

6	In the past month, did you always, usually, sometimes, or seldom:	Always	Usually	Sometimes	Seldom
	a. Wash your hands before preparing food for your baby?
	b. Wash the cutting board or counter before preparing food on it for your baby?
	c. Wash or rinse fresh fruits and vegetables at least 20 seconds and drain 2 minutes before preparing them for your baby?

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

Thank you very much for completing the 3-Day Food Checklists. All of your answers are very important to the study.

back cover

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File Type	application/msword
File Title	Source: EPA, NHANES, IFPS
Last Modified By	DHHS
File Modified	2008-09-19
File Created	2008-09-19

Milk and Cheese
Breast milk
Cow’s formula
Soy formula
Cow’s milk (whole, low fat, skim, chocolate)
Soy milk
Other milk (rice, goat, etc.)
Yogurt (all kinds)
Ice cream
Pudding

Eggs, Meats, & Other Main Dishes
Chicken
Turkey
Beef
Pork
Combination dinners
Eggs
Fish or shellfish
Peanut butter or nuts
Tofu or bean curd
Other meats

Beverages
Apple juice for babies
Apple juice
Grape juice
Orange juice
Pineapple juice
Other 100% juice
Sweet drinks (juice drinks, soda, Kool-aid)
Water

Fruits
Apple
Applesauce
Banana
Cantaloupe
Grapes
Orange
Peaches
Pear
Strawberries
Watermelon
Other fruits

Vegetables
Beans, green
Broccoli
Carrots
Cucumber
Corn
Dried beans & peas (refried, black, pintos)
French fries
Lettuce
Onion
Peas
Potatoes (no peel)
Potatoes (with peel)
Sweet potatoes
Tomatoes
Tomato sauce/paste
Other vegetables

Cereal/Grains
Baby cereal
Corn cereal or bread
Cheerios
Oatmeal
Bread, white
Bread, whole wheat
Rice, white
Pasta noodles
Other grains

Snacks & Sweets
Crackers
Teething biscuits
Corn chips
Potato chips
Graham crackers
Animal crackers
Cookies
Chocolate candy
Other sweets