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pdfForm Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 1 Evaluation Form
Your feedback is important! Please share your opinions about Session 1 of the BodyWorks program by filling out this survey.
I. Please rate each Session 1 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Introduction to BodyWorks—discussion
and PowerPoint presentation
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Introduction to girls’ BodyWorks
sessions
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Getting to know each other game (ice
breaker activity)
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Describe the goals of the kit overall, and the specific components targeting various family members
Understand the goals and expectations of the nine follow-up sessions
Participate in creating a comfortable and trusting tone for the group
Identify ground rules for discussions
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 2 Evaluation Form
Your feedback is important! Please share your opinions about Session 2 of the BodyWorks program by filling out this survey.
I. Please rate each Session 2 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Discussion on setting goals and
journaling
b.
Work It Out! Physical activity
List the activity you did:_______________
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Describe why goal setting and journaling helps people change their eating and physical activity habits
Set goals to improve my bone health and overall health
Use my journal to write down what I eat and the physical activities that I do
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls 3 Session Evaluation Form
Your feedback is important! Please share your opinions about Session 3 of the BodyWorks program by filling out this survey.
I. Please rate each Session 3 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Review of first week using the daily
journals
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Healthy smoothie demonstration
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Discussion on the basics of healthy
eating for children, teens, and adults
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Assess the information in my journal in order to set goals
Describe what foods make a healthy, balanced diet for children, teens, and adults
List the nutrients girls need to grow strong and healthy
Describe the importance of breakfast for girls’ bone and overall health
Not Confident
at all
Somewhat
confident
Very Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls 4 Session Evaluation Form
Your feedback is important! Please share your opinions about Session 4 of the BodyWorks program by filling out this survey.
I. Please rate each Session 4 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Discussion on fast food
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Serving size activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Team Up! physical activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
List the activity you did:_______________
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Know how to choose healthier foods and drinks at fast food restaurants
Describe the difference between serving sizes and portion sizes
Explain how portion sizes are related to reaching or keeping a healthy weight
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 5 Evaluation Form
Your feedback is important! Please share your opinions about Session 5 of the BodyWorks program by filling out this survey.
I. Please rate each Session 5 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Discussion on physical activity barriers
and benefits
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Discussion on limiting screen time
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Get Outdoors! physical activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
List the activity you did:_______________
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Describe barriers to physical activity and how to overcome them
List the benefits of physical activity
Describe how much physical activity girls need, including resistance and bone-strengthening exercises
Explain why spending less time in front of the TV or the computer gives us more time to be physically active
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 6 Evaluation Form
Your feedback is important! Please share your opinions about Session 6 of the BodyWorks program by filling out this survey.
I. Please rate each Session 6 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Activity to set family goals
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Activity to learn how to use the weekly
planner
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Discussion on involving the family in
planning, shopping, and cooking
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Set goals to eat healthier foods and become more physically active
Help my parent or caregiver use the weekly planner magnet to plan healthy meals
Help my parent or caregiver make shopping lists based on the meals and snacks planned for the week
Include foods with calcium and vitamin D in my meal planning
Help my parent or caregiver plan, shop for, and cook meals
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 7 Evaluation Form
Your feedback is important! Please share your opinions about Session 7 of the BodyWorks program by filling out this survey.
I. Please rate each Session 7 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Discussion on how to read nutrition
labels on food packages
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Nutrition label activity (scavenger hunt)
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Get in the Groove! physical activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
List the activity you did:_______________
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
Read and understand nutrition labels on food packages
Help my parent choose healthy foods at the supermarket
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 8 Evaluation Form
Your feedback is important! Please share your opinions about Session 8 of the BodyWorks program by filling out this survey.
I. Please rate each Session 8 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Discussion on body image, dieting, and
eating disorders
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Case study (story) about a girl with an
eating disorder
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Physical activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
List the activity you did:_______________
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
List the dangers of unhealthy dieting, especially for pre-teen and teen girls
Define the eating disorders anorexia nervosa and bulimia
Describe the health risks of eating disorders, including how they affect bone health
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 9 Evaluation Form
Your feedback is important! Please share your opinions about Session 9 of the BodyWorks program by filling out this survey.
I. Please rate each Session 9 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
“Reality Check” discussion
b.
Physical activity
List the activity you did:_______________
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Describe barriers to being physically active and eating healthy foods at home and at school
Describe ways to make it easier to eat healthy foods and be physically active at my home and school
Choose healthier breakfast, lunch, and snack foods that also contain calcium
Do the physical activity we participated in during today’s session on my own
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
BodyWorks for Girls Session 10 Evaluation Form
Your feedback is important! Please share your opinions about Session 10 of the BodyWorks program by filling out this survey.
I. Please rate each Session 10 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Media literacy quiz
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Activity analyzing a tobacco ad
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Handout and discussion on types of
advertising techniques
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
d.
Activity analyzing a magazine ad
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Describe how the media affects the body image of girls and women
Describe how ads encourage people to buy unhealthy foods and engage in unhealthy lifestyles
Look at the ways ads influence what people buy
Identify ways that I can maintain my new healthy habits, including being physically active for one hour each day
and eating more foods with calcium and vitamin D
List the most important actions that I have taken during BodyWorks to eat healthy foods and be physically
active on a regular basis
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/pdf |
| Author | Dana Martin Scott |
| File Modified | 2009-01-29 |
| File Created | 2009-01-29 |