0910-0545 – Health and Diet Survey
Proposed questionnaire
1. We have a few questions about your meals. By meals, we mean breakfast, lunch, and dinner. On average, how many days per week do you eat these meals?
Breakfast ENTER NUMBER______ [RANGE 0-7]
Lunch ENTER NUMBER______ [RANGE 0-7]
Dinner ENTER NUMBER______ [RANGE 0-7]
2. Restaurants sometimes display nutrition and calorie information about their items. This information may be shown on the menu or on napkins and placemats. Have you seen nutrition information in restaurants?
YES …………………………… 1
NO ……………………………. 2
DO NOT KNOW ……… 3
3. The next questions ask about different kinds of fat in foods we eat. Have you ever heard of the following types of fat? [RANDOMIZE ORDER]
YES …………………………… 1
NO ……………………………. 2
trans fat or trans fatty acid
saturated fat
omega 3 fatty acids
[IF ANSWER TO AN ITEM IS YES, ASK Q.4 FOR THE SAME ITEM; KEEP SAME ORDER AS IN Q.3.]
4. As far as you know, does trans fat or trans fatty acid (saturated fat or omega 3 fatty acids) raise the risk of heart disease, lower the risk of heart disease, or have no effect on the risk of heart disease, or don’t you know?
Raise the risk ...………… ……. 1
Lower the risk …………… .… 2
Have no effect …………………. 3
DO NOT KNOW ……… 4
| File Type | application/msword |
| File Title | Description of a Proposed Internet Survey to Collect Experimental Data Examining Differences between Phone- and Internet-Collect |
| Author | tempuser |
| Last Modified By | Jonna Capezzuto |
| File Modified | 2008-10-06 |
| File Created | 2008-10-06 |