Conduct Qualitative Research (Ethnographic, Site visit & Environmental scan interviews)

OMB#: 0584-0523

Expiration Date: 12/31/2012

Appendix G

Site Visit Interview Instrument

The following statement will be read after introductions:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB Control number. The valid OMB number for this collection is 0584-0523. The time required for this collection is estimated to average 180 minutes including the time for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collection of information.

We are talking to you and doing this site visit because of your familiarity with this topic. I have some questions to ask you. The interview takes an average of 180 minutes. Everything you say will be treated as private information and will not be shared with anyone outside of IMPAQ, Samuels & Associates and USDA, except as otherwise required by law. Participants will not be individually identified in any reports or publications and no one can be tied to an individual interview or statements.

ID:

Nutrition Education Program Name/Site:

Name of Interviewee:

Interviewer:

Date:

Time of Observation:

1. Number of children participating in the nutrition education lesson/session:

          

2. Ages or grade levels of participating students/children:

     

3. What is the level of engagement of the students/children? (i.e., level in which kids are interested, having fun, involved in the activity) [select one].

Not engaged at all

Minimally engaged

Very engaged

Extremely engaged

Other, please describe:

4. Other than the students/children, are others engaged in the program/activity? (check all that apply).

Parents

Principal

Teacher

School staff, please describe:

Other, please describe:

5. Who is teaching the class?

Teacher

School staff

Nutrition education program staff

Parent volunteer

Other, please describe:

6. Program setting:

After school program

School program

Health class

Gym class

Science curriculum

Stand alone program

Community program (name):

Other, please describe:      

7. Nutrition education topic/content areas being taught (check all that apply):

Fruits and/or vegetables

Whole grains

Calcium

Fat/Saturated fat

Salt/Sodium

Calories

Healthy beverages

General healthy eating

Physical activity

Other, please describe:      

8. Type of curriculum and materials used (explain):

     

9. Does the program include reference to or use of MyPyramid:

No

Yes, please describe:      

10. Does the program include reference to or use concepts from the Dietary Guidelines for Americans:

No

Yes, please describe:      

11. Is digital/social media or technology used?

No

Yes, please describe:      

12. In what ways does the site’s environment support the information being taught by the nutrition education program(s)? (check all that apply).

Presence of healthy food and beverage advertisement/signage

Healthy food/beverages are offered for sale

Healthy food/beverages offered as part of snack

School implementing IOM recommendations for meals and/or snacks

Other, please describe      

Environment does not support the program, please describe:      

13. Are there any nutrition policies for food and beverages served in the cafeteria, vending machines, snack carts, school stores, during meetings/school events and/or fundraisers?

No

Yes, please describe:      

Comments:      

14. Does the site host nutrition-related activities or events (i.e., farmers markets, lectures, health fairs, etc.)?

No

Yes, please describe:      

15. Does the site have other nutrition education-related programs?

No

Yes, please describe:      

16. Are there written policies on physical activity that encourage children to engage in physical activity during or outside of the school day?

No

Yes, please describe:      

17. Does the site have physical activity programs outside of PE classes?

No

Yes, please describe:      

18. In what ways are less healthy foods/beverages, such as sodas, fast foods, and brand names are being promoted and advertised at the site? (e.g., these include the classroom or other setting where the nutrition education program is taking place) [check all that apply].

None

School supplies

Vending machines

Banners or Posters

Drinking cups

Scoreboards

Other, please describe:      

19. Overall impressions and additional reflections from the observer:

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