Parents & Children

Food and Nutrition Service Evaluation of the Fresh Fruit and Vegetable Program (FFVP)

AppendixJ Student survey diary 11-20 ethnicity-race question updated

Parents & Children

OMB: 0584-0556

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Appendix J: Self Administered Student Questionnaire and Food Diary

Students in non-FFVP schools will be given a version of the Student Questionnaire that excludes questions 16a through 19. There will be no difference in the 1-Day Food Record for students at FFVP and non-FFVP schools.

F or office use only

ID: _______________

Self Administered Student Questionnaire
Please answer the questions below. Please check the box or fill in the blanks.
 This is not a test! There are no right or wrong answers. We want to know about you and what you like to eat.
 If you have any questions, please ask the interviewer.
Many of these questions are about the foods you ate or drank during the past 7 days (weekdays and weekend days). Think about all meals, snacks, and drinks you had each day and evening for all 7 days. Be sure to include food you ate at home, school, restaurants and anywhere else.

1. During the past 7 days, how many times did you drink any punch, Kool-Aid, sports drinks, energy drinks, vitamin water, or other fruit-flavored drinks?
D o NOT count 100% fruit juice or soda.
Mark only ONE box.
₁	I did not drink fruit-flavored drinks during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

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 number. The valid OMB control number for this information collection is 0584-xxxx. The time required to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Food and Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, VA 22302.

2 . During the past 7 days, how many times did you drink any regular (NOT diet) sodas or soft drinks?
Mark only ONE box.
₁	I did not drink regular soda during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

3. During the past 7 days, how many times did you drink any diet sodas or soft drinks?
Mark only ONE box.
₁	I did not drink diet soda during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
4. During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? D o NOT count fruit punch, Kool-Aid, sports drinks, energy drinks, vitamin water or other fruit-flavored drinks.
Mark only ONE box.
₁	I did not drink 100% fruit juice during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
5. During the past 7 days, how many times did you eat fruit? Include fresh, canned, frozen and dried fruit. Do NOT count fruit juice.
Mark only ONE box.
₁	I did not eat fruit during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
6 . During the past 7 days, how many times did you eat green salad? .
Mark only ONE box.
₁	I did not eat green salad during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
7 . During the past 7 days, how many times did you eat French fries, fried potatoes, or chips? Chips are potato chips, tortilla chips, Cheetos, puffs, corn chips, or other snack chips.
Mark only ONE box.
₁	I did not eat French fries, fried potatoes or chips during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
8 . During the past 7 days, how many times did you eat other salty snacks? Other salty snacks include cheese nibs, chex mix, gold fish crackers, Ritz, or other snac k chips.
Mark only ONE box.
₁	I did not eat other salty snacks during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
9. During the past 7 days, how many times did you eat other kinds of potatoes? Do *NOT* count French fries, fried potatoes, or potato chips.
Mark only ONE box.
₁	I did not eat potatoes during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
1 0. During the past 7 days, how many times did you eat carrots? Include cooked or raw carrots.
Mark only ONE box.
₁	I did not eat carrots during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

11. During the past 7 days, how many times did you eat other vegetables? Include fresh, canned, and frozen vegetables. D o NOT count green salad, potatoes, or carrots.
Mark only ONE box.
₁	I did not eat other vegetables during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

12. During the past 7 days, how many times did you eat a frozen dessert? A frozen dessert is a cold, sweet food like ice cream, sherbet, milk shake, frozen yogurt, an ice cream bar or a Popsicle.
Mark only ONE box.
₁	I did not eat frozen desserts during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day
13. During the past 7 days, how many times did you eat sweet rolls, doughnuts, Pop Tarts, Twinkies, Ho Hos, cookies, brownies, pies or cake?
Mark only ONE box.
₁	I did not eat things like cookies during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

14. During the past 7 days, how many times did you eat any candy? Count chocolate candy, candy bars, jelly bellies, gummies and Lifesavers. D o NOT count cookies or gum.
Mark only ONE box.
₁	I did not eat candy during the past 7 days
₂	1 to 3 times during the past 7 days	₅	2 times per day
₃	4 to 6 times during the past 7 days	₆	3 times per day
₄	1 time per day	₇	4 or more times per day

15. In a usual school week (weekdays), how often do you eat the following school meals? Mark only ONE box for each statement.
	Less than once a week or never	1 to 2 times a week	3 to 4 times a week	Every day
I usually eat the school lunch…	₁	₂	₃	₄
B. I usually bring lunch from home…	₁	₂	₃	₄
C. I usually eat the school breakfast….	₁	₂	₃	₄

Your school offers free fresh fruit and vegetable snacks BETWEEN meals.

16a. When they are offered, how often do you usually take the free fresh FRUIT snack? Mark only ONE box.
₁	Every time offered
₂	Most times offered
₃	Occasionally
₄	Never
₅	Haven’t seen it offered

16b. When they are offered, how often would you take the free fresh VEGETABLE snack? Mark only ONE box.
₁	Every time offered
₂	Most times offered
₃	Occasionally
₄	Never
₅	Haven’t seen it offered

16c. If you take the free fresh FRUIT snack when it is offered, how much of it do you usually eat? Mark only ONE box.
₁	I usually eat all of it
₂	I usually eat most of it
₃	I usually eat some of it
₄	I don’t usually eat any of it
₅	I don’t’ usually take the free fresh fruit
16d. If you take the free fresh VEGETABLE snack when it is offered, how much of it do you usually eat? Mark only ONE box.
₁	I usually eat all of it
₂	I usually eat most of it
₃	I usually eat some of it
₄	I don’t usually eat any of it
₅	I don’t usually take the free fresh vegetable

16e. If you do not take the fruit or vegetable snacks when they are offered, why not? Check ALL that apply.
₁	I already take them every time they are offered
₂	I don’t like fruits and vegetables
₃	I’m not hungry when they are offered
₄	I don’t like the look of the fruits and vegetables offered
₅	Another reason (please write why): ____________________________

17a. Have you heard or seen any information around school about the free fresh fruit

and vegetable snacks? Mark only ONE box.

₁

Yes

₂

If no, skip to question 18

17b. If you answered yes to question 17a, where did you see or hear the information? Check ALL that apply.
₁	School cafeteria staff
₂	Announcement over the loud speaker
₃	Poster around school
₄	Teacher/classroom
₅	Other (please describe where) __________________________________

18. How much do you agree or disagree with the following statements? Mark only ONE box for each statement.
	I agree very much 	I agree a little 	I disagree a little 	I disagree a lot 
A. I eat more fruits and vegetables on days when free fresh fruits and vegetable snacks are given at school than on other days	₁	₂	₃	₄
B. The free fresh fruits and vegetables they give us for school snacks look good and taste good.	₁	₂	₃	₄
C. I wish they would give us different kinds of fresh fruits and vegetables to eat for school snacks.	₁	₂	₃	₄
D. On days when I eat a free fresh fruit or a vegetable snack at school, I don’t eat other kinds of snacks.	₁	₂	₃	₄
E. I hope the free fresh fruit and vegetable snack program continues at our school.	₁	₂	₃	₄

19. If you could change anything about the free fresh fruit and vegetable snack

program, what changes would you make?

__________________________________________________________________________

20. How many servings of fruits and vegetables do you think are healthy to eat each day? Mark only ONE box.
₁	At least 1 serving
₂	1-2 servings
₃	3-4 servings
₄	5 servings or more
₅	Don’t know

21. How much do you agree or disagree with each of the following statements? Mark only ONE box for each statement.
	I agree very much 	I agree a little 	I disagree a little 	I disagree a lot 
A. I like most fruits	₁	₂	₃	₄
B. I like most vegetables	₁	₂	₃	₄
C. I like to try new kinds of fruits	₁	₂	₃	₄
D. I like to try new kinds of vegetables	₁	₂	₃	₄

22. For each fresh fruit or vegetable, mark how much you like it. Even if you can’t eat one of these foods now (for example, you have braces or some other reason) answer whether you like or don’t like it. Mark only ONE box for each fruit or vegetable.
	A lot 	A little 	Don’t like it 	Don’t Know Never tasted
A. Apples	₁	₂	₃	₄
B. Bananas	₁	₂	₃	₄
C. Strawberries	₁	₂	₃	₄
D. Kiwi Fruits	₁	₂	₃	₄
E. Oranges	₁	₂	₃	₄
F. Pears	₁	₂	₃	₄
G. Grapes	₁	₂	₃	₄
H. Cantaloupe	₁	₂	₃	₄
I. Peaches	₁	₂	₃	₄
J. Pineapple	₁	₂	₃	₄
K. Plums	₁	₂	₃	₄
L. Watermelon	₁	₂	₃	₄
M. Nectarines	₁	₂	₃	₄

22. Continued For each fresh fruit or vegetable, mark how much you like it. Mark only ONE box for each fruit or vegetable.
	A lot 	A little 	Don’t like it 	Don’t Know Never tasted
N. Blueberries	₁	₂	₃	₄
O. Tomatoes	₁	₂	₃	₄
P. Carrots	₁	₂	₃	₄
Q. Bell peppers	₁	₂	₃	₄
R. Zucchini	₁	₂	₃	₄
S. Celery	₁	₂	₃	₄
T. Broccoli	₁	₂	₃	₄
U. Cauliflower	₁	₂	₃	₄
V. Cucumbers	₁	₂	₃	₄
W. Lettuce	₁	₂	₃	₄
X. Snow peas	₁	₂	₃	₄

You are nearly finished! Just a couple of questions about you…

23. Are you Hispanic or Latino?

₁

Yes

₂

24. How do you describe yourself? Mark all that apply

₁ American Indian or Alaska Native White

₂ Asian

₃ Black or African American

₄ Native Hawaiian or Other Pacific Islander

₅ White

25. What language do you use with your parents most of the time?

₁ English

₂ Spanish

₃ Other (please describe) ________________________________________

Thank you for completing this questionnaire!

YOUR NAME_________________________________

TIME TO START RECORDING___________________

TIME TO STOP RECORDING____________________

Please ask your parent or caregiver to help you fill in the details of foods and drinks that you have at home.

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 number. The valid OMB control number for this information collection is 0584-xxx. The time required to complete this information collection is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Please carry this booklet every place you go today (all day) and tomorrow morning and record your food and drinks. Also, please fill in the blanks below:

TODAYS’ DATE: _____/____/____

Month Day Year

DAY OF THE WEEK________________

Are you a boy or girl?  Boy  Girl

Age: ______ years old Grade: ________

Name of School _______________________________

Your Teacher’s Name ___________________________

Your appointment is scheduled for

_____________________at _____________am/pm

BE SURE TO BRING THIS COMPLETED RECORD WITH YOU TO SCHOOL TOMORROW FOR YOUR APPOINTMENT WITH THE INTERVIEWER. If you have any questions, please call

________________________

[School interviewer]

Thank you!

START RIGHT AFTER THIS CLASS

	Write down in your booklet everything you eat and drink from now until you go to bed tonight, and anything you eat or drink tomorrow morning up to the time you bring your diary to the interviewer.
	Each time you start eating or drinking, write down the time and circle if MORNING, AFTERNOON-EVENING
	Check off the type of meal (breakfast, lunch, dinner or snack).
	Check or write down the place where your food was eaten (home, friend’s house, school, restaurant), etc.).
	Write only one food or drink on each line.
	Describe your food and drinks. Give brand names and list ingredients in homemade dishes. Ask your parents/caregivers to help you with this at home
	Describe how your food was prepared (fried, baked, broiled, grilled, boiled, microwaved, etc.).
	Write down if fruits and vegetables were fresh, canned, dried, or frozen (e.g. frozen peas, boiled).
	Measure your food and drinks using your cups, spoons, ruler or shapes whenever possible.
	Be sure to tell us how much you actually eat or drink, even if you did not finish it all.
	Write down any snacks, candy or drinks you have.

Use your cups, spoons, and the drawings of the ruler or shape pictures below to describe how much you ate or drank,

(or you may draw the size of your food on the back of your records pages)

Use your cups, spoons, and the drawings below to describe how much you ate or drank

(or you may draw the size of your food on the back of your records pages)

Use your ruler or these pictures to help you with sizes.

FOOD DESCRIPTION GUIDE

Find the food you are trying to describe and record as much information as you can. Ask your parent/caregiver to help you. Even if you cannot describe a food be sure to write it in your diary.

DRINKS- type? Amount? Any ice?

Juice- 100%/Juice Drinks/Juice Blends

brand name, flavor
regular or low calorie, added calcium or other fortified
juice or drink?

Milk

white, chocolate, other flavor
whole, 2%, 1%, ½%, skim (nonfat)

Soda/Sparkling Water/Vitamin Waters

brand name
Sweetened/flavored or unsweetened/unflavored
regular or diet

Water

-tap or bottled

Sports drinks, Energy drinks

-brand

BREADS/ BAGELS/ BISCUITS/ MUFINS

type: white, whole wheat, cornbread,bagel
store bought (give brand name), bakery, or homemade
any additions? (butter, margarine, mayo, jelly)
muffins: bran, carrot, blueberry, choc chip

measure diameter of top and bottom and give height

tortilla: corn or flour, plain or fried, diameter

RICE/PASTA/NOODLES/SPAGHETTI

rice: white, brown, convenience mix brand(eg. Rice A Roni
pasta/noodles: regular, or wholegrain
any additions? (butter, oil, gravy, sauce, cheese, etc.)

SNACKS

Chips/Snackfoods/crackers

-brand name, package weight ,or measure with cups

type (potato, tortilla, rice cakes, pork rinds, cheese curls, etc.) and brand name
regular, or baked?
any additions? (dips, cheese auce, salsa, etc.)

Popcorn

type (air, oil, microwaved, or commercial packaged)
microwaved/commercial packaged: give brand name, regular or light
plain, butter flavored, or butter/margarine added
weight from bag, number of cups

DESSERT OR SNACKS

Cookies/Cakes/Donuts/Pastries

-brand name, description, measurements

type ( chocolate chip, yellow cake,)
store bought (give brand name), bakery, homemade – mix or scratch?
any frosting? (flavor; from mix, scratch or can)
number of cake layers, shape, measurements

Candy/Chocolate

brand name and/or description
weight from package
bars: package size (funsize, snacksize,,kingsize)

Ice Cream/Frozen Yogurt/Frozen Dessert

-brand name, regular or softserve

flavor, any additions? (nuts, sprinkles, whipped cream, sauce, etc.)
regular or lowfat, yogurt or ice cream

Pies

type (fruit, cream, custard, sweet potato,
crust (dough, graham cracker) homemade or store bought, single or double crust
any additions? (ice cream, whipped cream)

CASSEROLES/RECIPES

name of dish or recipe, (spaghetti, tacos, Hamburger Helper)
list and describe all or main ingredients
preparation (baked, fried, stir fried, etc.)
any sauce? (tomato, cream, soy)
any vegetables? type?
Any meat? Type?
Noodles or rice or potato?

Any additions- sour cream, hot sauce, cheese

FAST FOODS

name of restaurant
name of food (Big Mac, BK Broiler, Pepperoni Pizza,
add anything or take anything off? (ketchup, mustard, lettuce, tomato,
size of order (small, medium, large)

FATS/SALAD DRESSINGS/SPREADS

Butter, Margarine, Lard, Pork Fat

brand name
butter: regular, whipped, butter/margarine blend
margarine: stick, tub or squeeze, regular, light, fat free or ultra-light,

Oil and Shortening

brand name
oil: type (canola, soybean, vegetables, etc.)
shortening: regular or butter flavor

Salad Dressing

type (French, Honey Mustard, Italian, Ranch, etc.)
store bought (give brand name) or homemade (give ingredients if known)
regular, low calorie, lowfat, or nonfat

Mayonaise: brand name; real or mayo-type; regular, lowfat or nonfat

MEATS/CHICKEN/FISH

Meat

type (beef, pork, veal, etc.)
cut (ribs, chops, steak, ground, pigs feet, liver)
marinated or basted with fat (specify type)
fat eaten or trimmed away
preparation (fried, baked, grilled, broiled, etc.)
give measurements including thickness, with or without bone
any additions? (steak sauce, garlic butter, gravy, etc.)
luncheon meats: deli or store bought (give brand name); regular, thin sliced or shaved; regular, lowfat or fat free
hot dogs (beef, pork, turkey, chicken; regular, lowfat or fat free)

Chicken

piece (breast, wing, thigh, drumstick, etc.) or type meat (light or dark)
breading or coating, skin eaten or removed, with or without bone
marinated or basted with fat (specify type)
preparation (fried, baked, stewed, barbequed, pan or deep fried, etc.)
for nuggets give number eatenm for chicken strips give number and measurements
any additions (BBQ sauce, gravy, etc.)
skin eaten? (If removed, before or after cooking?)

Fish/Shellfish

type (catfish, sole, salmon, shrimp, bass, etc.)
fresh, frozen, canned (oil or water pack, drained or rinsed)
breaded or batter dipped, marinated or basted with fat (specify type)
preparation (fried, baked, broiled, steamed, etc.)

crabs: type (Alaskan, blue, Softshell, etc.) give number of legs or whole crabs; any additions? (tartar sauce, melted butter, cocktail sauce, etc.)

VEGETABLES/BEANS

type vegetable: squash, corn, greens, okra, broccoli, etc.
type beans: pinto, kidney, blackeyed peas, refried, etc.
preparation (boiled, microwaved, steamed, stir fried,)
canned, fresh, frozen
seasoned with meat? (bacon, hamhocks, fatback, etc.)
fat in preparation or at tables (specify type)
potatoes: with or without skin

Frozen Meals

brand name and description of foods

package weigiht and amount eaten

SAMPLE

REMINDER: WRITE ONE FOOD PER LINE.

Time/Meal

(write in time, circle time of day, check meal)

Place Eaten

(check)

Food or Drink

(Write Type, brand, description)

Amount I Ate or Drank

(Write in cups, inches, ounces from packages)

1 2: 30 pm MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Grilled cheese sandwich – white bread, American cheese

Bread – 4 inches square

Cheese – 3 inches square

Left the crusts

1 2: 30 pm MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Chocolate milk, 1% fat

1 carton 8 fl oz of milk

1 2: 30 pm MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Pears, canned, tasted sweet

½ cup

Left about half of it

1 2: 30 pm MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Strawberry vanilla yogurt

(Yoplait Lite)

4 oz - one carton

3 : 15 pm MORNING/ AFTERNOON/ EVENING

 ₁Breakfast

 ₂Lunch

 ₃Dinner

₄Snack

 ₁School

₂Home

 ₃Restaurant

 ₄Friend’s home

 ₅Other ____________

Nestle crunch bar

2.5 x 1 x .5 in- 1 oz on wrapper

SAMPLE

REMINDER: WRITE ONE FOOD PER LINE.

Time/Meal

(write in time, circle time of day, check meal)

Place Eaten

(check)

Food or Drink

(Write Type, brand, description)

Amount I Ate or Drank

(Write in cups, inches, ounces from packages)

7 : 30 pm MORNING/ AFTERNOON/ EVENING

 ₁Breakfast

 ₂Lunch

₃Dinner

 ₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Spaghetti – homemade

Spaghetti noodles, meat sauce (made with ground beef, onion, tomato paste, tomato sauce), grated cheese on top

Spaghetti noodles - ¾ cup

Meat sauce - ½ cup

Grated cheese 1tbsp

Ate it all!

7 : 30 pm MORNING/ AFTERNOON/ EVENING

 ₁Breakfast

 ₂Lunch

₃Dinner

 ₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Coke, diet

12 oz – 1 can

7 : 30 am MORNING/ AFTERNOON/ EVENING

₁Breakfast

 ₂Lunch

 ₃Dinner

 ₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Honey Nut Cheerios, Kelloggs

3/4 cup

7 : 30 am MORNING/ AFTERNOON/ EVENING

₁Breakfast

 ₂Lunch

 ₃Dinner

 ₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

1% milk

7 fl oz

1 0:00 am MORNING/ AFTERNOON/ EVENING

 ₁Breakfast

 ₂Lunch

 ₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Blueberries, fresh

1/3 cup

PRACTICE SHEET

REMINDER: WRITE ONE FOOD PER LINE.

Time/Meal

(write in time, circle time of day, check meal)

Place Eaten

(check)

Food or Drink

(Write Type, brand, description)

Amount I Ate or Drank

(Write in cups, inches, ounces from packages)

___:_____ MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING

₁Breakfast

₂Lunch

₃Dinner

₄Snack

₁School

₂Home

₃Restaurant

₄Friend’s home

₅Other ____________

Coder ______________________

Interviewer ______________________

Participant ID: ____________ Age: __________ Gender: _________

Day of the week: _______________________________	Date: ______ ______ / ______ ______ /______ ______
	Month	Day	Year

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

	REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS.
Time/Meal (write in time, circle time of day, check meal)		Place Eaten ( check )	Food or Drink (Write Type, brand, description)	Amount I Ate or Drank (Write in cups, inches, ounces from packages)
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________
				.
___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

___:_____ MORNING/ AFTERNOON/ EVENING ₁Breakfast ₂Lunch ₃Dinner ₄Snack		₁School ₂Home ₃Restaurant ₄Friend’s home ₅Other ____________

Use your cups, spoons, ruler or shape pictures for how much you ate or drank, or you may draw the size of your food on the back of this page.

File Type	application/msword
File Title	Appendix J: Self Administered Student Questionnaire
Author	Lorrene Ritchie
Last Modified By	rgreene
File Modified	2010-01-14
File Created	2010-01-14