Form 1076-0XXX Let's Move! Indian Country - School Survey

Let’s Move! in Indian Country, School Survey Questions
1. Introduction
OMB Control No. 1076-0XXX
Expires: __________
An interagency collaboration between the First Lady’s Let’s Move! Initiative, the Departments of the Interior (AS-IA,
Bureau of Indian Affairs, and Bureau of Indian Education), Agriculture, Health and Human Services (IHS), and Education
has been formed to reduce disproportionately high obesity rates and improve the health of Native youth. This survey is
designed to determine what resources are already available at schools in Indian Country and those serving significant
populations of Native youth and more importantly what further resources are needed in order to create healthy school
environments for all students.

Questions with an asterisk * in front of the question number must be answered in order to complete the survey

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to collect
information regarding what resources are already available at schools in Indian Country and those serving significant
populations of Native youth and what further resources are needed in order to create healthy school environments for all
students. The information is provided by respondents voluntarily. In compliance with the Paperwork Reduction Act of
1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number
and an expiration date. The number and expiration date are at the top left corner of the form. An agency may not sponsor
or conduct, and a person is not required to respond to, a request for information unless it displays a currently valid OMB
Control Number. The public reporting burden is estimated to average 1 hour per respondent. This includes the time
needed to understand the questions, gather the information, complete and submit the form. Comments regarding the
burden or other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office
of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

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Let’s Move! in Indian Country, School Survey Questions
2. Background Information

* 1. Please tell us what school you are representing.
* 2. Please select which State your school is in.
United States

6

States/Territories

3. Please indicate your position/title/role in your school.
c
d
e
f
g

Administrator

c
d
e
f
g

Teacher

c
d
e
f
g

Counselor

c
d
e
f
g

Librarian

c
d
e
f
g

Other

Other (please specify)

* 4. Is your school located on a reservation?
j
k
l
m
n

Yes

j
k
l
m
n

No

* 5. Please check all that apply.
c
d
e
f
g

Elementary School

c
d
e
f
g

BIE Operated

c
d
e
f
g

Middle School

c
d
e
f
g

Grant school

c
d
e
f
g

High School

c
d
e
f
g

Contract school

c
d
e
f
g

Day School

c
d
e
f
g

Public

c
d
e
f
g

Boarding School

c
d
e
f
g

Private

* 6. Total number of students attending school.

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Let’s Move! in Indian Country, School Survey Questions
7. Has your school in the past, or does your school currently have, a partnership or
working agreement(s) with any Federal, State or local land management
agency/agencies?
j
k
l
m
n

Yes

j
k
l
m
n

No

8. Please list the land management agencies your school has worked with or currently
works with (if any)
5
6

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Let’s Move! in Indian Country, School Survey Questions
3. Federal Nutrition Programs
1. Please check all that apply.
c
d
e
f
g

My school offers breakfast to students

c
d
e
f
g

My school offers lunch to students

c
d
e
f
g

My school provides snacks of fruits and vegetables to students during the school day outside of breakfast and lunch times

c
d
e
f
g

My school provides meals to students during the summer or other long breaks when school is not in session

c
d
e
f
g

My school has programming for children during the summer months but does not provide a meal associated with this activity

c
d
e
f
g

My school provides after school snacks and/or an after school meal to students

c
d
e
f
g

My school has after school programming (clubs, sports, etc.) but does not provide a snack or meal associated with these activities

c
d
e
f
g

My school provides nutrition education to students

c
d
e
f
g

My school has a fruit or/and vegetable garden

c
d
e
f
g

My school serves food acquired from local or regional producers to students

c
d
e
f
g

My school has a competitive food element, such as vending machines

2. Through State government agencies, schools can implement a number of programs,
which are eligible for reimbursement, to provide meals, snacks, as well as nutrition
education materials. Please check all the programs in which your school participates.
c
d
e
f
g

National School Lunch Program

c
d
e
f
g

School Breakfast Program

c
d
e
f
g

Summer Food Service Program

c
d
e
f
g

Fresh Fruits and Vegetables Program

c
d
e
f
g

Child and Adult Care Food Program (after-school meal)

c
d
e
f
g

Team Nutrition (nutrition education curriculum)

c
d
e
f
g

Use of MyPyramid materials

c
d
e
f
g

BackPack Program

c
d
e
f
g

Not sure

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Let’s Move! in Indian Country, School Survey Questions
3. Other than programs listed above, does your school currently receive funding or
resources from State Government, Federal Government, or other entities, for specific
food and/or nutrition programs (other than USDA Free and Reduced Meals Program)
j
k
l
m
n

Yes

j
k
l
m
n

No

4. The HealthierUS School Challenge is an awards program that recognizes schools
participating in the National School Lunch Program, which provides a healthy
environment for children through the promotion of healthy eating and physical activity.
Please check all that apply.
j
k
l
m
n

Our school knows about the HealthierUS School Challenge

j
k
l
m
n

Our school received information about the HealthierUS School Challenge

j
k
l
m
n

Our school applied for the HealthierUS School Challenge

j
k
l
m
n

Our school made a decision not to apply for the HealthierUS School Challenge

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Let’s Move! in Indian Country, School Survey Questions
4. President's Active Lifestyle Award Challenge (PALA)

* 1. Please select all of the answers relevant to your school and the Presidents Active
Lifestyle Award(PALA)Challenge
c
d
e
f
g

We have received information about PALA

c
d
e
f
g

We have previously participated in PALA

c
d
e
f
g

We currently participate in PALA

c
d
e
f
g

We do not participate in PALA

2. If your school DOES NOT participate in PALA, please select the answer most
appropriate to your reason
c
d
e
f
g

We do not know about PALA

c
d
e
f
g

We do not have the personnel to manage additional projects

c
d
e
f
g

We do not have the infrastructure (i.e. gymnasium)

c
d
e
f
g

It is not a good fit for our school

c
d
e
f
g

Other

Other (please specify)

5
6

3. Our school would like to receive more information about the PALA.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
5. Carol M. White Physical Education Program (PEPS)

* 1. Please select all of the answers relevant to your school and the Carol M. White
Physical Education Program (PEPS)
j
k
l
m
n

We have received information about PEPS

j
k
l
m
n

We have previously participated in PEPS

j
k
l
m
n

We currently participate in PEPS

j
k
l
m
n

We do not participate in PEPS

2. If you are participating in PEPS, when does the funding expire?
MM
Date

DD
/

YYYY
/

3. If your school DOES participate in PEPS, please describe the project the funds were
for, including funds provided and when those funds were received
5
6

4. If your school DOES NOT participate in PEPS, which situation is most relevant?
c
d
e
f
g

We applied for PEPS, but did not receive funding

c
d
e
f
g

We have never applied for a PEPS grant

5. If your school applied, but DID NOT receive funding, please explain the reason you
were denied:
5
6

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Let’s Move! in Indian Country, School Survey Questions
6. If you have never applied for PEPS, please select the answers most relevant to your
reason
c
d
e
f
g

We did not know about PEPS

c
d
e
f
g

We do not have the capacity/skills to write grants

c
d
e
f
g

We do not have personnel to manage additional projects

c
d
e
f
g

It is not a good fit for our schools

c
d
e
f
g

Other

Other (please specify)

5
6

7. Our school would like to receive more information about PEPS.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
6. Physical Education Curriculum

* 1. Please select the choices most relevant to your school
j
k
l
m
n

We use a specific physical education curriculum

j
k
l
m
n

We had previously used a specific physical education curriculum, but no longer do

j
k
l
m
n

We have never used a specific physical education curriculum

2. What is the name of the physical education curriculum your school uses or has
used?
5
6

3. If you have stopped using a specific physical education curriculum, or have never
used one, please elaborate on your reasons
5
6

4. Our school would like to receive more information about physical education curricula.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
7. Diabetes Education in Tribal Schools Curriculum (DETS)

* 1. Please select all of the answers relevant to your school and the Diabetes Education in
Tribal Schools Curriculum (DETS)
c
d
e
f
g

We have received information about DETS

c
d
e
f
g

We have previously participated in DETS

c
d
e
f
g

We currently participate in DETS

c
d
e
f
g

We do not participate in DETS

2. If your school no longer or has never participated in the DETS program, please select
all answers that apply
c
d
e
f
g

We did not know about DETS

c
d
e
f
g

We do not have the resources to support the curriculum

c
d
e
f
g

We do not have the personnel to manage additional projects

c
d
e
f
g

It is not a good fit for our school

c
d
e
f
g

Other

Other (please specify)

3. Our school would like to receive additional information about the DETS.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
8. Wellness Policies
1. Do any local health programs (IHS, tribal, other) provide any wellness/prevention
services in your school, either during school hours or after school? If so, please specify
both the health program and the service(s) provided.
5
6

* 2. Does your school currently have a Health and/or Wellness Policy?
j
k
l
m
n

Yes

j
k
l
m
n

We used to, but no longer have one

j
k
l
m
n

We have never had one

j
k
l
m
n

Not Sure

3. If you DO have a health and/or wellness policy, please briefly describe its content
5
6

4. If you DO NOT have a health and/or wellness policy, what has prevented your school
from implementing one?
c
d
e
f
g

Do not know about wellness policies

c
d
e
f
g

Do not have resouces to manage additional projects

c
d
e
f
g

Not a good fit for our schools

c
d
e
f
g

Other

Other (please specify)

5
6

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Let’s Move! in Indian Country, School Survey Questions
9. Safe Rides
1. If your school buses students, what is the maximum busing distance?
Miles

2. If your school DOES NOT bus students, please best explain how they get to school:
5
6

* 3. Please select all of the answers relevant to your school and the Safe Routes to
School Program
c
d
e
f
g

We have received information about the Safe Routes to School Program

c
d
e
f
g

We have previously participated in the Safe Routes to School Program

c
d
e
f
g

We currently participate in the Safe Routes to School Program

c
d
e
f
g

We do not participate in the Safe Routes to School Program

4. If your school DOES participate in the Safe Routes to School Program, please
describe the project the funds were for, including funds provided and when those funds
were received
5
6

5. If your school DOES NOT participate in the Safe Routes to School Program, please
select the answer(s) that best describe what has prevented your school from applying
or re-applying to receive Safe Routes to School funding?
c
d
e
f
g

Do not know about Safe Routes to School

c
d
e
f
g

Do not have capacity/skill to write grant

c
d
e
f
g

Do not have personnel to manage additional projects

c
d
e
f
g

Not elligible for the Safe Routes to School Program funding

c
d
e
f
g

Other

Other (please specify)

5
6

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Let’s Move! in Indian Country, School Survey Questions
6. Our school would like to receive more information about the Safe Routes to School
Program.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
10. Corporation for National Community Service (CNCS)

* 1. Has your school ever used the Corporation for National Community Service (CNCS),
including AmeriCorps, Learn and Serve American, Senior Corps, or VISTA members?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Not Sure

2. If your school HAS used or DOES use any of the CNCS programs as listed in question
1 in this section, please elaborate to what extent:
5
6

3. If your school has NEVER used any of the CNCS programs as listed in question 1 in
this section, please select all that apply
c
d
e
f
g

Do not know about CNCS

c
d
e
f
g

Do not have capacity/skill to write grant

c
d
e
f
g

Do not have personnel to manage additional projects

c
d
e
f
g

Do not have funds for CNCS

c
d
e
f
g

Other

Other (please specify)

4. Our school would like to receive more information about CNCS programs.
c
d
e
f
g

Yes

c
d
e
f
g

No

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Let’s Move! in Indian Country, School Survey Questions
11. Future Help
1. Is your school interested in technical assistance? If so, please select the focus areas
you would be interested in:
c
d
e
f
g

Not interested

c
d
e
f
g

Creating a Healthier School Environment

c
d
e
f
g

Increasing Access to Healthy, Affordable Food

c
d
e
f
g

Increasing Physical Activity

c
d
e
f
g

Creating Healthy, Comprehensive Food Systems Policies

c
d
e
f
g

Creating a School Fruit and Vegetable Garden

c
d
e
f
g

Community/Parental involvement in promotion programs

Other (please specify)

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Let’s Move! in Indian Country, School Survey Questions
12. Other
1. Please indicate any additional comments or suggestions that you may have to assist
with the development of the Let's Move! in Indian Country initiative.
5
6

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Let’s Move! in Indian Country, School Survey Questions
13. Thank You!
Thank you for participating in our survey. We greatly appreciate your time and are excited about the opportunity to help
your schools.

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