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
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Please answer the questions below. Please check the box or fill in the blanks.
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This is not a test! There are no right or wrong answers. We want to know about you and what you like to eat.
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If you have any questions, please ask the interviewer.
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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. |
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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? |
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D o NOT count 100% fruit juice or soda.
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Mark only ONE box. |
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1 |
I did not drink fruit-flavored drinks during the past 7 days |
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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 |
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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?
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Mark only ONE box. |
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1 |
I did not drink regular soda during the past 7 days |
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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 |
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3. During the past 7 days, how many times did you drink any diet sodas or soft drinks?
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Mark only ONE box. |
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1 |
I did not drink diet soda during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not drink 100% fruit juice during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat fruit during the past 7 days |
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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?
.
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Mark only ONE box. |
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1 |
I did not eat green salad during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat French fries, fried potatoes or chips during the past 7 days |
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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. |
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Mark only ONE box. |
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1 |
I did not eat other salty snacks during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat potatoes during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat carrots during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat other vegetables during the past 7 days |
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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.
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Mark only ONE box. |
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1 |
I did not eat frozen desserts during the past 7 days |
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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?
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Mark only ONE box. |
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1 |
I did not eat things like cookies during the past 7 days |
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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 |
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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.
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Mark only ONE box. |
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1 |
I did not eat candy during the past 7 days |
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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. |
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Less than once a week or never |
1 to 2 times a week |
3 to 4 times a week |
Every day |
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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. |
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1 |
Every time offered |
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2 |
Most times offered |
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3 |
Occasionally |
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4 |
Never |
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5 |
Haven’t seen it offered |
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16b. When they are offered, how often would you take the free fresh VEGETABLE snack? Mark only ONE box. |
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1 |
Every time offered |
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2 |
Most times offered |
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3 |
Occasionally |
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4 |
Never |
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5 |
Haven’t seen it offered |
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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. |
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1 |
I usually eat all of it |
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2 |
I usually eat most of it |
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3 |
I usually eat some of it |
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4 |
I don’t usually eat any of it
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5 |
I don’t’ usually take the free fresh fruit |
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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. |
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1 |
I usually eat all of it |
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2 |
I usually eat most of it |
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3 |
I usually eat some of it |
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4 |
I don’t usually eat any of it
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5 |
I don’t usually take the free fresh vegetable |
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16e. If you do not take the fruit or vegetable snacks when they are offered, why not? Check ALL that apply. |
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1 |
I already take them every time they are offered |
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2 |
I don’t like fruits and vegetables |
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3 |
I’m not hungry when they are offered |
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4 |
I don’t like the look of the fruits and vegetables offered |
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5 |
Another reason (please write why): ____________________________ |
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17a. Have you heard or seen any information around school about the free fresh fruit and vegetable snacks? Mark only ONE box. |
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1 |
Yes |
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2 |
No |
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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. |
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1 |
School cafeteria staff |
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2 |
Announcement over the loud speaker |
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3 |
Poster around school |
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4 |
Teacher/classroom |
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5 |
Other (please describe where) __________________________________ |
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18. How much do you agree or disagree with the following statements? Mark only ONE box for each statement. |
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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. |
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1 |
At least 1 serving |
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2 |
1-2 servings |
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3 |
3-4 servings |
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4 |
5 servings or more |
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5 |
Don’t know |
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21. How much do you agree or disagree with each of the following statements? Mark only ONE box for each statement. |
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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.
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A lot |
A little |
Don’t like it |
Don’t Know Never tasted |
A. Apples |
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1 |
2 |
3 |
4 |
B. Bananas |
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1 |
2 |
3 |
4 |
C. Strawberries |
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1 |
2 |
3 |
4 |
D. Kiwi Fruits |
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1 |
2 |
3 |
4 |
E. Oranges |
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1 |
2 |
3 |
4 |
F. Pears |
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1 |
2 |
3 |
4 |
G. Grapes |
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1 |
2 |
3 |
4 |
H. Cantaloupe |
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1 |
2 |
3 |
4 |
I. Peaches |
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1 |
2 |
3 |
4 |
J. Pineapple |
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1 |
2 |
3 |
4 |
K. Plums |
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1 |
2 |
3 |
4 |
L. Watermelon |
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1 |
2 |
3 |
4 |
M. Nectarines |
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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. |
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A lot |
A little |
Don’t like it |
Don’t Know Never tasted |
N. Blueberries |
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1 |
2 |
3 |
4 |
O. Tomatoes |
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1 |
2 |
3 |
4 |
P. Carrots |
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1 |
2 |
3 |
4 |
Q. Bell peppers |
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1 |
2 |
3 |
4 |
R. Zucchini |
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1 |
2 |
3 |
4 |
S. Celery |
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1 |
2 |
3 |
4 |
T. Broccoli |
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1 |
2 |
3 |
4 |
U. Cauliflower
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1 |
2 |
3 |
4 |
V. Cucumbers |
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1 |
2 |
3 |
4 |
W. Lettuce |
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1 |
2 |
3 |
4 |
X. Snow peas |
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1 |
2 |
3 |
4 |
You are nearly finished! Just a couple of questions about you…
23. Are you Hispanic or Latino?
1 |
Yes |
2 |
No |
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!
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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. 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.
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 |
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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. |
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Each time you start eating or drinking, write down the time and circle if MORNING, AFTERNOON-EVENING |
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Check off the type of meal (breakfast, lunch, dinner or snack). |
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Check or write down the place where your food was eaten (home, friend’s house, school, restaurant), etc.). |
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Write only one food or drink on each line. |
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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 |
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Describe how your food was prepared (fried, baked, broiled, grilled, boiled, microwaved, etc.). |
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Write down if fruits and vegetables were fresh, canned, dried, or frozen (e.g. frozen peas, boiled). |
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Measure your food and drinks using your cups, spoons, ruler or shapes whenever possible. |
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Be sure to tell us how much you actually eat or drink, even if you did not finish it all. |
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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)
(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.
Use your cups, spoons, and the drawings below to describe how much
you ate or drank
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
Milk
Soda/Sparkling Water/Vitamin Waters
Water -tap or bottled
Sports drinks, Energy drinks -brand
BREADS/ BAGELS/ BISCUITS/ MUFINS
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RICE/PASTA/NOODLES/SPAGHETTI
SNACKS
Chips/Snackfoods/crackers -brand name, package weight ,or measure with cups
Popcorn
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DESSERT OR SNACKS
Cookies/Cakes/Donuts/Pastries -brand name, description, measurements
Candy/Chocolate
Ice Cream/Frozen Yogurt/Frozen Dessert -brand name, regular or softserve
Pies
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CASSEROLES/RECIPES
Any additions- sour cream, hot sauce, cheese
FAST FOODS
FATS/SALAD DRESSINGS/SPREADS
Butter, Margarine, Lard, Pork Fat
Oil and Shortening
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Salad Dressing
Mayonaise: brand name; real or mayo-type; regular, lowfat or nonfat
MEATS/CHICKEN/FISH
Meat
Chicken
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Fish/Shellfish
crabs: type (Alaskan, blue, Softshell, etc.) give number of legs or whole crabs; any additions? (tartar sauce, melted butter, cocktail sauce, etc.)
VEGETABLES/BEANS
Frozen Meals
package weigiht and amount eaten |
SAMPLE REMINDER: WRITE ONE FOOD PER LINE. |
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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
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Chocolate milk, 1% fat |
1 carton 8 fl oz of milk |
1 2: 30 pm MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Pears, canned, tasted sweet |
½ cup Left about half of it |
1 2: 30 pm MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Strawberry vanilla yogurt (Yoplait Lite) |
4 oz - one carton |
3 : 15 pm MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Nestle crunch bar |
2.5 x 1 x .5 in- 1 oz on wrapper |
SAMPLE REMINDER: WRITE ONE FOOD PER LINE. |
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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
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Coke, diet |
12 oz – 1 can |
7 : 30 am MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Honey Nut Cheerios, Kelloggs |
3/4 cup |
7 : 30 am MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
1% milk |
7 fl oz |
1 0:00 am MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
Blueberries, fresh |
1/3 cup |
PRACTICE SHEET REMINDER: WRITE ONE FOOD PER LINE. |
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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
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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Coder
______________________ Interviewer
______________________
Participant ID: ____________ Age: __________ Gender: _________ |
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Day of the week: _______________________________ |
Date: ______ ______ / ______ ______ /______ ______ |
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Month |
Day |
Year |
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REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS. |
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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. |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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.
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REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS. |
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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.
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REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS. |
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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.
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REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS. |
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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.
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REMINDER: WRITE ONE FOOD PER LINE AND DO NOT WRITE IN SHADED AREAS. |
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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.
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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) |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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___:_____ MORNING/ AFTERNOON/ EVENING
1 Breakfast 2 Lunch 3 Dinner 4 Snack |
1 School 2 Home 3 Restaurant 4 Friend’s home 5 Other ____________ |
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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 |