Form 2 National Youth Physical Activity and Nutrition Survey

NATIONAL YOUTH PHYSICAL ACTIVITY AND NUTRITION STUDY

Appendix C- NYPANS Questionnaire

NYPANS Student Questionnaire

OMB: 0920-0832

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C. National Physical Activity and Nutrition Survey Questionnaire

Form Approved

OMB No.: 0920-xxxx

Expiration Date: xx-xx-xxxx

National

Youth Physical Activity and Nutrition Survey

This survey is about health behavior. It has been developed so you can tell us what you do that may affect your health. The information you give will be used to develop better health education for young people like yourself.

DO NOT write your name on this survey. The answers you give will be kept secure. No one will know what you write. Answer the questions based on what you really do.

Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.

The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.

Make sure to read every question. Fill in the circles completely. When you are finished, follow the instructions of the person giving you the survey.

Thank you very much for your help.

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-XXXX)

DIRECTIONS

Use a #2 pencil only.
Make dark marks.
Fill in a response like this:
- Y es No
If you change your answer, erase your old answer completely.

1. How old are you?

12 years old or younger
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older

2. What is your sex?

Female
Male

3. In what grade are you?

9th grade
10th grade
11th grade
12th grade
Ungraded or other grade

4. Are you Hispanic or Latino?

5. What is your race? (Select one or more responses.)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

6. How tall are you without your shoes on?

Directions: Write your height in the shaded blank boxes. Fill in the matching oval below each number.

Example: Answer:

Height		Height
Feet	Inches	Feet	Inches
5	7
3	0	3	0
4	1	4	1
5	2	5	2
6	3	6	3
7	4	7	4
	5		5
	6		6
	7		7
	8		8
	9		9
	10		10
	11		11

7. How much do you weigh without your shoes on?

Directions: Write your weight in the shaded blank boxes. Fill in the matching oval below each number.

Example

Weight in Pounds			Weight in Pounds
1	5	2
1	0	0	1	0	0
2	1	1	2	1	1
3	2	2	3	2	2
4	3	3	4	3	3
5	4	4	5	4	4
	5	5		5	5
	6	6		6	6
	7	7		7	7
	8	8		8	8
	9	9		9	9
	10	10		10	10
	11	11		11	11

The next 10 questions ask about physical activity.

Yesterday, were you physically active for a total of at least 60 minutes? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)

During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)

1 day
2 days
3 days
4 days
5 days
6 days
7 days

On how many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work? (Include activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, and the Internet.)

I do not play video or computer games or use a computer for something that is not school work
Less than 1 hour per day
1 hour per day
2 hours per day
3 hours per day
4 hours per day
5 or more hours per day

On an average school day, how many hours do you spend watching DVDs or videos? Include DVDs or videos you watch on a TV, computer, iPod, or other portable device.

I do not watch DVDs or videos on an average school day
Less than 1 hour per day
1 hour per day
2 hours per day
3 hours per day
4 hours per day
5 or more hours per day

On an average school day, how many hours do you watch TV?

I do not watch TV on an average school day
Less than 1 hour per day
1 hour per day
2 hours per day
3 hours per day
4 hours per day
5 or more hours per day

In an average week when you are in school, on how many days do you go to physical education (PE) classes?

0 days
1 day
2 days
3 days
4 days
5 days

How much do you agree or disagree with the following statement? I enjoyed the physical education (PE) classes I took at school during the past 12 months.

I did not take PE during the past 12 months
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

During the past 12 months, on how many sports teams did you play? (Include teams run by your school or community groups.)

0 teams
1 team
2 teams
3 or more teams

For each of the following activities, please mark 1) whether you did the activity during the past 12 months, and 2) on how many of the past 7 days you did the activity. Think about activities you did before and after school, in the evenings, and on the weekends, by yourself or with others. Include activities you did just for fun or in competition. Do not include PE or gym class.

Activity	Past 12 months	Number of days in past 7 days
Active video games (Wii, Dance Dance Revolution [DDR])	Yes No	0 1 2 3 4 5 6 7
Aerobics	Yes No	0 1 2 3 4 5 6 7
Baseball/softball	Yes No	0 1 2 3 4 5 6 7
Basketball	Yes No	0 1 2 3 4 5 6 7
Bike riding	Yes No	0 1 2 3 4 5 6 7
Cheerleading	Yes No	0 1 2 3 4 5 6 7
Dance	Yes No	0 1 2 3 4 5 6 7
Field hockey/street hockey/roller hockey	Yes No	0 1 2 3 4 5 6 7
Football	Yes No	0 1 2 3 4 5 6 7
Frisbee	Yes No	0 1 2 3 4 5 6 7
Golf	Yes No	0 1 2 3 4 5 6 7
Gymnastics/tumbling	Yes No	0 1 2 3 4 5 6 7
Hiking	Yes No	0 1 2 3 4 5 6 7
Horseback riding	Yes No	0 1 2 3 4 5 6 7
Ice hockey	Yes No	0 1 2 3 4 5 6 7
Ice skating	Yes No	0 1 2 3 4 5 6 7
Jumping rope	Yes No	0 1 2 3 4 5 6 7
Lacrosse	Yes No	0 1 2 3 4 5 6 7
Marching band	Yes No	0 1 2 3 4 5 6 7
Martial arts (karate, tae kwon do, judo, etc.)	Yes No	0 1 2 3 4 5 6 7
Racquetball	Yes No	0 1 2 3 4 5 6 7
Roller blading/roller skating	Yes No	0 1 2 3 4 5 6 7
Running/jogging	Yes No	0 1 2 3 4 5 6 7
Skateboarding	Yes No	0 1 2 3 4 5 6 7
Soccer	Yes No	0 1 2 3 4 5 6 7
Surfing	Yes No	0 1 2 3 4 5 6 7
Swimming	Yes No	0 1 2 3 4 5 6 7
Tennis	Yes No	0 1 2 3 4 5 6 7
Track and field	Yes No	0 1 2 3 4 5 6 7
Volleyball	Yes No	0 1 2 3 4 5 6 7
Waterskiing	Yes No	0 1 2 3 4 5 6 7
Walking	Yes No	0 1 2 3 4 5 6 7
Weighlifting	Yes No	0 1 2 3 4 5 6 7
Wrestling	Yes No	0 1 2 3 4 5 6 7
Yoga	Yes No	0 1 2 3 4 5 6 7

How many TVs are in your home? (If you sleep in more than one home, answer based on the home you sleep in most.)

0
1
2
3
4
5 or more

Do you have a TV in your bedroom? (If you have more than one bedroom, answer based on the bedroom you sleep in most.)

In an average week when you are in school, on how many days do you walk or ride your bike to school when weather allows you to do so?

0 days
1 day
2 days
3 days
4 days
5 days

In an average week when you are in school, on how many days do you walk or ride your bike home from school when weather allows you to do so?

0 days
1 day
2 days
3 days
4 days
5 days

How much do you agree or disagree with each statement? (Circle one number for each statement).
When I am physically active		Strongly Disagree		Disagree		Neither Agree nor Disagree		Agree	Strongly Agree
I enjoy it.		1		2		3		4	5
I find it fun.		1		2		3		4	5
it gives me energy.		1		2		3		4	5
my body feels good.		1		2		3		4	5
it gives me a strong feeling of success.		1		2		3		4	5

How much do you agree or disagree with each statement? (Circle one number for each statement).
	Strongly Disagree		Disagree		Neither Agree nor Disagree		Agree			Strongly Agree
At home there are enough pieces of sports equipment (such as balls, bicycles, skates) to use for physical activity.	1		2		3		4			5
There are playgrounds, parks, or gyms close to my home that are easy for me to get to.	1		2		3		4			5
It is safe to be physically active by myself in my neighborhood.	1		2		3		4			5
The next 4 questions ask about the adults you live with. (Circle one number for each item).
During a typical week, how often does an adult in your household…	Never		1-2 times/week		3-4 times/week		5-6 times/week			Daily
encourage you to do physical activities or play sports?	1		2		3		4			5
do a physical activity or play sports with you?	1		2		3		4			5
provide transportation to a place where you can do physical activities or play sports?	1		2		3		4			5
watch you participate in physical activities or sports?	1		2		3		4			5

The next 16 questions ask about food you ate or drank during the past 7 days. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.

During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)

I did not eat fruit during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you eat green salad?

I did not eat green salad during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you eat potatoes? (Do not count French fries, fried potatoes, or potato chips.)

I did not eat potatoes during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you eat French fries or other fried potatoes, such as home fries, hash browns, or tater tots? (Do not count potato chips.)

I did not eat French fries or other fried potatoes during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you eat carrots?

I did not eat carrots during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)

I did not eat other vegetables during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day

4 or more times per day

During the past 7 days, how many times did you eat pizza? (Count pizza from a restaurant or school, frozen pizza, and pizza you made at home.)

I did not eat pizza during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)

I did not drink 100% fruit juice during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not count diet soda or diet pop.)

I did not drink soda or pop during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a can, bottle, or glass of diet soda or pop, such as Diet Coke, Diet Pepsi, or Sprite Zero?

I did not drink diet soda or pop during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a can, bottle, or glass of a sports drink such as Gatorade or PowerAde? (Do not count low-calorie sports drinks such as Propel or G2.)

I did not drink sports drinks during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a can, bottle, or glass of an energy drink, such as Red Bull or Jolt? (Count both regular and diet energy drinks. Do not count sports drinks such as Gatorade or PowerAde).

I did not drink energy drinks during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a cup, can, or bottle of coffee, coffee drinks, or any kind of tea?

I did not drink coffee, coffee drinks, or tea during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a can, bottle, or glass of a sugar-sweetened beverage such as lemonade, sweetened tea or coffee drinks, flavored milk, Snapple, or Sunny Delight? (Do not count soda or pop, sports drinks, energy drinks, or 100% fruit juice.)

I did not drink sugar-sweetened beverages during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many times did you drink a bottle or glass of plain water? Count tap, bottled, and unflavored sparkling water.

I did not drink water during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day

During the past 7 days, how many glasses of milk did you drink? (Count the milk you drank in a glass or cup, from a carton, or with cereal. Count the half pint of milk served at school as equal to one glass.)

I did not drink milk during the past 7 days
1 to 3 glasses during the past 7 days
4 to 6 glasses during the past 7 days
1 glass per day
2 glasses per day
3 glasses per day
4 or more glasses per day

The next 6 questions ask about food you ate or drank yesterday. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.

Yesterday, how many times did you eat fruit? (Do not count fruit juice.)

0 times
1 time
2 times
3 times
4 times
5 or more times

Yesterday, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)

0 times
1 time
2 times
3 times
4 times
5 or more times

Yesterday, how many times did you eat green salad?

0 times
1 time
2 times
3 times
4 times
5 or more times

Yesterday, how many times did you eat potatoes? (Do not count French fries, fried potatoes, or potato chips.)

0 times
1 time
2 times
3 times
4 times
5 or more times

Yesterday, how many times did you eat carrots?

0 times
1 time
2 times
3 times
4 times
5 or more times

Yesterday, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)

0 times
1 time
2 times
3 times
4 times
5 or more times

The next 2 questions ask about how many cups of fruits and vegetables you eat or drink each day. Use the examples below as a guide when you answer these questions.

1 CUP of FRUIT =	1 CUP of VEGETABLES=
1 small apple	3 broccoli spears, 5 in long
1 large banana	1 cup of cooked leafy greens
8 large strawberries	2 cups of lettuce or raw greens
2 large plums	12 baby carrots
32 seedless grapes	1 large potato or sweet potato
1 cup of 100% juice	2 large celery stalks
½ cup dried fruit	1 cup of cooked beans

About how many cups of fruit (including frozen, canned, and dried fruit and 100% fruit juice) do you eat or drink each day?

None
½ cup or less
½ to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

About how many cups of vegetables (including frozen and canned vegetables and 100% vegetable juice) do you eat or drink each day?

None
½ cup or less
½ to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

The next 16 questions ask about meals you might have eaten during the past 7 days and the food available to you at home and at school.

93. During the past 7 days, on how many days did you eat breakfast or a morning meal?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

94. During the past 7 days, on how many days did you eat lunch?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

95. When you eat lunch at school, where do you usually get the food you eat?

I never eat lunch at school
From home
From somewhere at school
From somewhere else

96. When you get lunch at school, what do you usually get?

I do not get lunch at school
A complete school lunch from the school cafeteria (a meal sold at school that costs the same price every day)
A la carte items from the school cafeteria (items sold separately from a complete school lunch)
Salad bar from the school cafeteria
Fast food from the school cafeteria (such as McDonalds, Taco Bell, or KFC)
Food from a school vending machine, school canteen, or school store

97. In an average week when you are in school, on how many days do you eat all or part of a complete school lunch?

0 days
1 day
2 days
3 days
4 days
5 days

98. In an average week when you are in school, on how many days do you bring your own lunch to school from home?

0 days
1 day
2 days
3 days
4 days
5 days

99. On how many of the past 7 days did you eat dinner or an evening meal?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

100. On school days, where do you usually eat dinner?

I do not usually eat dinner on school days
At home
At school
At a restaurant, including fast food restaurants
In a car, bus, or train
At a friend or relative’s house
Some place else

101. When you eat dinner at home, how often is a television on while you are eating?

I do not eat dinner at home
Never
Rarely
Sometimes
Most of the time
Always

102. During the past 7 days, on how many days did you eat dinner at home with at least one of your parents or guardians?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

103. During the past 7 days, on how many days did you eat at least one meal or snack from a fast food restaurant such as McDonald’s, Taco Bell, or KFC?

0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

104. How often are there fruits or vegetables to snack on in your home, such as carrots, celery, apples, bananas, or melon?

Never
Rarely
Sometimes
Most of the time
Always

105. How often are there foods such as chips, cookies, or cakes to snack on in your home?

Never
Rarely
Sometimes
Most of the time
Always

106. Does your school have a vending machine that students can use to purchase soda or pop, sports drinks, or fruit drinks that are not 100% juice, such as Coke, Gatorade, or Sunny Delight?

Yes
No
Not sure

107. Does your school have a vending machine that students can use to purchase snacks such as chips, cookies, crackers, cakes, pastries, chocolate candy, or other kinds of candy?

Yes
No
Not sure

108. Does your school have a vending machine that students can use to purchase fruits or vegetables? (Count dried fruit, such as raisins.)

Yes
No
Not sure

The next 12 questions ask about body weight.

How do you describe your weight?

Very underweight
Slightly underweight
About the right weight
Slightly overweight
Very overweight

Which of the following are you trying to do about your weight?

Lose weight
Gain weight
Stay the same weight
I am not trying to do anything about my weight

During the past 30 days, did you exercise to lose weight or to keep from gaining weight?

During the past 30 days, did you eat less food, fewer calories, or foods low in fat to lose weight to keep from gaining weight?

During the past 30 days, did you eat more fruits and vegetables to lose weight or keep from gaining weight?

During the past 30 days, did you eat fewer calories to lose weight or keep from gaining weight?

During the past 30 days, did you skip meals to lose weight or keep from gaining weight?

DO NOT WRITE BELOW THIS LINE

OFFICE USE ONLY

[___________________ ]

0	0	0	0
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9

16. During the past 30 days, did you drink more water to lose weight or keep from gaining weight?

117. During the past 30 days, did you smoke cigarettes to help you lose weight or keep from gaining weight?

Yes
No
I do not smoke

During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?

During the past 30 days, did you take any diet pills, powders, or liquids without a doctor’s advice to lose weight or to keep from gaining weight? (Do not include meal replacement products such as Slim Fast.)

During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?

File Type	application/msword
File Title	Please circle the number that most closely describes how much you agree or disagree with each statement
Author	gagrubb
Last Modified By	arp5
File Modified	2009-06-11
File Created	2009-03-09