Facilitator Feedback Forms (10 forms)

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

BodyWorks Parent/Caregiver Post‐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:
DAUGHTER #2 (IF APPLICABLE):
DAUGHTER #3 (IF APPLICABLE):
/
MM

/
DD

/
YY

MM

/
DD

/
YY

MM

/
DD

YY

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

City 1

City 2

City 3

1. 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
2. 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

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

3a. 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)

Not At All
A Priority
(1)

Low
Priority
(2)

Priority
(3)

High
Priority
(4)

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?
e. Planning, shopping, and making healthy meals
and snacks for my family?
f. Preventing osteoporosis later in life?
3b. 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….
a. Consume foods and drinks that are high in
calcium and vitamin D as part of regular meals
and snacks every day?

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

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).
4. 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.

This is not
a barrier
for me at
all
(4)

Very hard
(1)

Somewhat
hard
(2)

Not very
hard
(3)

BodyWorks Parent/Caregiver Post‐Test Survey…2 

This set of questions asks what you know about healthy eating and exercise.
5. 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

6. 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
7. 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

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

† False

9. 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.

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

10. 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?
d. Limit computer and TV time for my family so that
we can spend more time being active?

(1)

(2)

(3)

(4)

e. Plan what physical activities my family will do for
the week?
f. 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
i.

Describe about how the media (TV, Radio, Internet)
may affect my health habits?

BodyWorks Parent/Caregiver Post‐Test Survey…3 

11. 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

12. 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

13. 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

14. 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

15. Thinking about the past 7 days, on how many days did
YOU… (Choose one response for each activity.)
a. Write in a journal what you ate and how much physical activity
you did?

† 500 IU

0
Days

1-2
Days

3-4
Days

5-7
Days

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. Ensure that healthy meals were prepared for your family?
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?
m. Choose to be active instead of watching TV and/or sitting at
the computer?

BodyWorks Parent/Caregiver Post‐Test Survey…4 

16. Thinking about what you eat on a NORMAL
DAY, how many times do you eat or drink…
(Choose one response for each item.)

0
Times

1
Time

2
Times

3
Times

4
Times

5+
Times

a. Milk or milk products (yogurt, cheese) or milk
substitutes (soy)?

b. Soda or pop?

c.

d. Meat and beans (meat, fish, chicken, tofu, egg,
peanut butter, cooked beans, nuts, seeds)?

e. Potato chip or French fries?

f.

g. Candy, cookies and/or cake?

h. Grains (bread, cereal, rice, pasta)?

Fruits (including 100% fruit juice)?

Vegetables (including those in mixtures: soup,
stir fry, gumbo, stew, casserole, taco, omelets)?

For each statement, choose one response on a scale
of 1 (strongly disagree) to 4 (strongly agree).
17. During the next month, I plan to…
a. Make healthy food choices.
b. Consume more foods and drinks high in calcium and
vitamin D.
c. Exercise more often.
d. Exercise more often with my daughter.
e. Set/work toward nutrition and physical activity goals.
f. Plan for, shop, and prepare healthy meals and
snacks for my family.
g. Eat a healthy breakfast every day.
h. Eat meals together with my family.
i. Help my daughter work toward her physical activity
and nutrition goals.

Strongly
Disagree
(1)

Disagree
(2)

Agree
(3)

Strongly
Agree
(4)

BodyWorks Parent/Caregiver Post‐Test Survey…5 

18. How many sessions did you attend? (circle one)
1

2

3

4

5

6

7

8

9

10

More than 10

19. What got in the way of your attending all of the sessions? (Choose one or more.)

†
†
†
†
†
†
†
†
†
†
†
†

I attended all of the sessions
Transportation
Childcare
Work
Schedule conflicts
Time of day sessions were held
Not able to/did not do the assignment from the previous week
Not interested in the topic of the specific session
Topic didn’t seem important to me
I did not like the trainer
I did not like the other group members
Other:

20. Below is a list of the items in the BodyWorks Toolkit. In columns I and II, please check only
those items that you used alone, and only those items that you used with your daughter.
In column III, only for the items you DID use, please tell us how helpful they were on a scale of 1
(Not at all Helpful) to 4 (Very Helpful).

BodyWorks Toolkit Items

Column I

Column II

I used this
on my own

I used this
with my
daughter

a. Body Basics
b. Family Food and Fitness
Journal
c. Best Journal Ever! for
girls
d. Bodyworks DVD
e. Weekly Planner
f. Recipe Book
g. Shopping Lists
h. BodyWorks 4Teens
i. Act Now: A Parent’s
Guide to Girls’ Bone
Health
j. BodyWorks For Guys

Column III
How helpful was this item?
Not at
Not
Very
all
Very
Helpful
Helpful
Helpful Helpful
(3)
(4)
(1)
(2)

21. If parts of the BodyWorks Toolkit were not helpful, what could make them better?
(Write your answer in the space below.)

BodyWorks Parent/Caregiver Post‐Test Survey…6 

For each statement, choose one response on a
scale of 1 (strongly disagree) to 4 (strongly agree).

Strongly
Disagree

Disagree

Agree

Strongly
Agree

a. Showed up on time

1

2

3

4

b. Was well organized

1

2

3

4

c.

1

2

3

4

d. Communicated well with the group

1

2

3

4

e. Treated me with respect

1

2

3

4

f.

Included everyone in activities

1

2

3

4

g. Managed any problems that arose

1

2

3

4

h. Knew about the topics we discussed

1

2

3

4

22. The Trainer(s)…

Was a positive role model

23. Overall, how satisfied were you with the BodyWorks program sessions? (Choose one.)
† Not at all satisfied
† Not very satisfied
† Satisfied
† Very satisfied
24. What would make the program sessions better (i.e., shorter lessons, more activities)? (Write your
answer in the space below.)

25. Have you participated in any health education programs about nutrition or physical activity other
than BodyWorks within the last 10 weeks?
No

Yes

If you checked “yes,” please, please describe the program:
________________________________________________________________________
26. Have you seen or participated in the following Best Bones Forever (BBF) campaign activities
within the last 10 weeks? (Choose one or more.)
Website

Publications

Events or presentations

None

Other: _______

BodyWorks Parent/Caregiver Post‐Test Survey…7