Facilitator Feedback Forms (10 forms)

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

 BodyWorks Parent/Caregiver Pre‐Test Survey 

The Office on Women’s Health is trying to find out how well the BodyWorks program helps you, your
daughter(s), and the rest of your family. You will help improve the program by taking this survey.
This survey will take you about 30 minutes to complete. It includes questions about health habits and the
BodyWorks program that relate to you, your daughter(s), and your family. When the survey asks you
about “your daughter”, please think of your daughter who will be participating in BodyWorks for Teens as
you answer. If you have more than one daughter participating, please think of the oldest. Your survey
answers are confidential.
Parent/Caregiver Initials
Please write down your FIRST and LAST Initials:
[Example: Jane Smith would write J.S.]

First Initial

Last Initial

Date of Birth of Daughter(s) in BodyWorks Program
Please write down the DATE of BIRTH of your daughter(s) participating in the BodyWorks Program with you.
[Example: If your daughter was born on May 22, 1995, write: 05/22/95]
DAUGHTER #1:
/
MM

DAUGHTER #2 (IF APPLICABLE):
/

DD

/
YY

MM

DAUGHTER #3 (IF APPLICABLE):

/
DD

/
YY

MM

/
DD

YY

Location
In what city do you live? (Choose one.)

City 1

City 2

City 3

1. How did you hear about BodyWorks? (Choose one or more.)
† School
† Work place
† Flyer/Brochure

† Teacher
† Friend
† Neighbor

† Public announcement
† Doctor or other health care provider
† Other:

2. What, if anything, interested you in the BodyWorks program? (Choose one or more.)

†
†
†
†
†
†
†

I wanted to learn more about nutrition and/or preparing healthier meals for my family
I wanted to learn more about being physically active
I was concerned about my daughter’s health and/or weight
I was concerned about my own health and/or weight
I wanted to participate in an activity with my daughter
I wanted group support to help me make nutritional and/or physical activity changes for my family
Other:

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

3. Which of the statements below best describes how you feel right now about making changes to
your eating and exercise habits? (Choose one)
† I have not given any thought to making changes
† I am thinking about making changes in the future, perhaps six months from now
† I am getting ready to make changes soon, perhaps within the next month
† I am making changes right now
† I have already made changes and am working on maintaining my new habits
4. How motivated are you to make changes to your eating and exercise habits? (Choose one.)
† Not motivated at all
† Somewhat motivated
† Motivated
† Very motivated
† I do not need to make changes
5a. For each activity, choose one response on a scale of
1 (not at all a priority) to 4 (high priority).

Not At All
A Priority
(1)

Low
Priority
(2)

Priority
(3)

High
Priority
(4)

e. Planning, shopping, and making healthy meals and
snacks for my family?

f.

Not At All
A Priority
(1)

Low
Priority
(2)

Priority
(3)

High
Priority
(4)

a. Consume foods and drinks that are high in calcium and
vitamin D as part of regular meals and snacks every
day?

b. Do different kinds of physical activities?

c.

d. Set goals and write in a journal about her eating and
activity habits?

e. Help plan, shop for, and make healthy meals and
snacks with me?
f. Build strong bones during childhood and adolescence to
prevent osteoporosis later in life?

How much of a priority to YOU is…
a. Consuming foods and drinks that are high in calcium
and vitamin D as part of regular meals and snacks every
day?
b. Doing different kinds of physical activities?
c.

Exercising for the amount of time recommended for
adults?
d. Setting goals and writing in a journal about my eating
and activity habits?

Preventing osteoporosis later in life?

5b. For each activity, choose one response on a scale of
1 (not at all a priority) to 4 (high priority).
How much of a priority to you as a PARENT/
CAREGIVER is it that your daughter….

Exercise for the amount of time recommended for
children and teens every day?

BodyWorks Parent/Caregiver Pre‐Test Survey… 2 

Below is a list of common reasons, or barriers,
why people say they do not exercise. For each
barrier, choose one response on a scale of 1
(very hard) to 4 (this is not a barrier for me at
all).
6. Think back to the last month. How hard was it
for you to overcome these barriers so you
could exercise?
a. I am too tired.
b. I don't have time.
c. I don’t like to exercise.
d. I don’t like the way I look or feel in exercise
clothes.
e. I don't have a place to exercise or the right
equipment.
f.

I don't feel safe exercising outdoors where I
live.
g. I don’t have anyone to exercise with.

Very hard

Somewhat
hard

Not very
hard

This is
not a
barrier for
me at all

(1)

(2)

(3)

(4)

This set of questions asks what you know about healthy eating and exercise. 
7. By age ___, females have built most of their bone mass (how solid and strong bones are from
the inside) for the rest of their lives. (Choose one.)
† 5 yrs

† 13 yrs

† 18 yrs

† 30 yrs

† 55 yrs

8. What, if anything, can pre-teen and teen girls do to build strong bones? (Choose one or more.)
† Drink soda daily
† Consume foods and drinks high in calcium and vitamin D daily
† Exercise daily for the recommended amount of time
† Get a lot of rest daily
† Avoid smoking, alcohol, and caffeine
9. When reading a food label you should look for the serving size to determine how much is an
appropriate amount to eat. (Choose one.)
† True

† False

10. Eating smaller portion sizes is one way to reach or keep a healthy weight. (Choose one.)
† True

† False

11. The dangers of unhealthy dieting for pre-teen and teen girls can be: (Choose one.)
† Not getting enough nutrients to grow and develop
† Greater risk for weaker bones and osteoporosis later in life
† Greater risk for an eating disorder
† All of the above
† None of the above. There is no such thing as an unhealthy diet.

BodyWorks Parent/Caregiver Pre‐Test Survey… 3 

For each activity, choose one response on a
scale of 1 (not sure at all) to 4 (very sure).

Not At All
Sure

Not Very
Sure

Sure

Very Sure

12. How sure are you that you can …
a. Talk with my family about how we can eat
healthier foods and be more physically active
each day?
b. Choose healthier foods and drinks at home
including foods with calcium and vitamin D?
c. Choose healthier food and drinks at
restaurants, including fast food restaurants?

(1)

(2)

(3)

(4)

d. Limit computer and TV time for my family so
that we can spend more time being active?
e. Plan what physical activities my family will do
for the week?

Plan for, shop, and make healthy meals for my
family each week?

g. Understand nutrition labels on food packaging

h. Exercise, including bone-strengthening
physical activities

f.

13. How many minutes of DAILY physical activity are recommended for pre-teen and teen girls to
stay healthy? (Choose one.)
† 20 minutes

† 30 minutes

† 45 minutes

† 60 minutes

† 90 minutes

14. How many days per week of bone-strengthening activity are recommended for pre-teen and
teen girls to build strong bones? (Choose one.)
† 1 Day

† 2 Days

† 3 Days

† 4 Days

† 5 Days

15. How many milligrams (mg) of calcium are recommended DAILY for pre-teen and teen girls to
build strong bones and stay healthy? (Choose one.)
† 200 mg

† 500 mg

† 750 mg

† 900 mg

† 1300 mg

16. How many international units (IU) of vitamin D are recommended DAILY for pre-teen and teen
girls to build strong bones and stay healthy? (Choose one.)
† 100 IU

† 200 IU

† 300 IU

† 400 IU

† 500 IU

BodyWorks Parent/Caregiver Pre‐Test Survey… 4 

17. Thinking about the past 7 days, on how many days did
YOU… (Choose one response for each activity.)

0
Days

1-2
Days

3-4
Days

5-7
Days

a. Write in a journal what you ate and how much physical activity
you did?
b. Work toward goals you set for yourself /your family to eat
healthy foods and be physically active
c. Consume daily recommended amounts of calcium and vitamin
D?
d. Plan healthy meals and snacks for the week ahead for your
family, including making a shopping list?
e. Shop for healthy foods and beverages for your family?

f.

g. Ensure that healthy snacks were prepared for your family?

h. Eat a healthy breakfast

i.

Eat a meal together with family members?

j.

Exercise for the amount of time recommended for adults?

k.

Exercise with your daughter?

l.

Do bone-strengthening exercises?

Ensure that healthy meals were prepared for your family?

m. Choose to be active instead of watching TV and/or sitting at the
computer?

18. Thinking about what you eat on a
NORMAL DAY, how many times do you eat or
drink… (Choose one response for each item.)
a. Milk or milk products (yogurt, cheese) or milk
substitutes (soy).
b. Soda or pop.
c. Fruits (including 100% fruit juice).
d. Meat and beans (meat, fish, chicken, tofu,
egg, peanut butter, cooked beans, nuts,
seeds).
e. Potato chips or French fries.
f. Vegetables (including those in mixtures:
soup, stir fry, gumbo, stew, casserole, taco,
omelets).
g. Candy, cookies and/or cake.
h. Grains (bread, cereal, rice, pasta).

0
Times

1
Time

2
Times

3
Times

4
Times

5+
Times

BodyWorks Parent/Caregiver Pre‐Test Survey… 5 

About You
19. What is your gender? (Choose one.)
20. How old are you? (Choose one.)
18 - 21
22 - 30
31 - 40

Male
41 - 50

21. Are you Hispanic or Latino? (Choose one.)

Female

51 - 60
No

60+
Yes

22. What is your race? (Choose one or more.)
Black/African American
American Indian or Alaska Native
White
Native Hawaiian or other Pacific Islander
23. What is the highest level of education you have completed? (Choose one.)
Elementary school (grades 1-8)
Associate degree (2-year)
Some high school (grades 9-11)
College graduate (4-year)
High school graduate or GED
Graduate degree

Asian

24. Please check the category that represents your annual income. (Choose one.)
Less than $15,000
$50,000-$75,000
$15,000-$35,000
Over $75,000
35,000-$50,000
25. Number of children: (Choose one.)
None

1

2

3

4 or more

26. Have you participated in any health education programs about nutrition or physical activity
other than BodyWorks?
No
Yes
If you checked “yes,” please, please describe the program:
______________________________________________________________________
27. Have you seen or participated in the following Best Bones Forever (BBF) campaign activities?
(Choose one or more.)
Website

Publications

Events or presentations

28. How would you describe your health? (Choose one.)
Poor
Fair
Good
Very good
29. How tall are you?
____________
Feet and inches

None

Other: ____________
Excellent

30. How much do you weigh?
____________
Pounds

BodyWorks Parent/Caregiver Pre‐Test Survey… 6 

The following questions are about the daughter(s) that came with you to BodyWorks. If only one
daughter attended BodyWorks with you, please only complete the section labeled “Daughter #1”
Daughter #1
31. What is your relationship to the girl who is participating in the BodyWorks program with you?
(Choose one.)
Mother or stepmother
Father or stepfather
Grandmother or aunt
Grandfather or uncle
Other:
32. How many days does she live with you on average during the week? (Choose one.)
Less than 1 day
1 day
2 days
3-4 days
5-6 days
7 days
33. How old is she? (Choose one.)
9 or less
10
11
12
14 and above

13

35. How tall is she?
____________
Feet and inches

34. What grade is she in? (Choose one.)
4th
5th
6th
7th
8th +
36. How much does she weigh?
____________
Pounds

Daughter #2 (if applicable)
37. What is your relationship to the girl who is participating in the BodyWorks program with you?
(Choose one.)
Mother or step mother
Father or step father Grandmother or aunt
Grandfather or uncle
Other:
38. How many days does she live with you on average during the week? (Choose one.)
Less than 1 day
1 day
2 days
3-4 days
5-6 days
7 days
39. How old is she? (Choose one.)
9 or less
10
11
12
14 and above

13

41. How tall is she?
____________
Feet and inches

40. What grade is she in? (Choose one.)
4th
5th
6th
7th
8th +
42. How much does she weigh?
____________
Pounds

Daughter #3 (if applicable)
43 What is your relationship to the girl who is participating in the BodyWorks program with you?
(Choose one.)
Mother or step mother
Father or step father Grandmother or aunt
Grandfather or uncle
Other:
44. How many days does she live with you on average during the week? (Choose one.)
Less than 1 day
1 day
2 days
3-4 days
5-6 days
7 days
45. How old is she? (Choose one.)
9 or less
10
11
12
14 and above
47. How tall is she?
____________
Feet and inches

13

46. What grade is she in? (Choose one.)
4th
5th
6th
7th
8th +
48. How much does she weigh?
____________
Pounds

BodyWorks Parent/Caregiver Pre‐Test Survey… 7