Appendix C - Questionnaire final clean copy 7 27 11

Appendix C

Questionnaire for Experiment

Form Approved: OMB No. XXXXXX

Expiration Date: XXXXXX

PUBLIC Disclosure Burden Statement

Public reporting burden for this collection of information is estimated to average 15 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. 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:

Department of Health and Human Services
Food and Drug Administration
CFSAN/PRB Comments/HFS-24
5100 Paint Branch Parkway
College Park, MD 20740-3835.

Screening criteria: Have to be at least 18 years old.

Task One

Single Product

Respondents will see only the NF label (no front panel) but will be told the name of the product

Note that the label information you see in this study may or may not be the same as you would see at the grocery store.

{Note to reader: participants will be randomized to perform either the single-product or the two-product. task first. There will be both a healthy and unhealthy version of each

Time will be recorded for each question.}

TASK ONE Purchase Intention and Healthfulness Rating –

Purchase Intent

Please answer the questions below based on what you can see on the Nutrition Facts label shown on your screen.

Please look at the Nutrition Facts Label provided to answer these questions.

A1. Assume you were shopping for [FOOD], how likely would you be to purchase this [FOOD]? Use a five point scale where 1 means “not at all likely” and 5 means “very likely.”

Not at all likely				Very likely
1	2	3	4	5	Don’t know

A2. If you were going to eat [FOOD], how healthy of a choice would this [FOOD] be? Use a five point scale where 1 means “not at all healthy,” and 5 means “very healthy.”

Not at all healthy				Very healthy
1	2	3	4	5	Don’t know

A3. Based on this Nutrition Facts label, how much of each of the following things would you would say that one SERVING of this FOOD has? Use a five point scale where 1 means “none” and 5 means “A lot.” Please provide a rating for each item listed.

	None 1	2	3	4	A lot 5	Don’t know
Calories
Total Fat
Sodium
Saturated Fat
Sugars
Vitamin A
Dietary Fiber
Iron

Ability to Use Label (TIME TOTAL)

Please answer the questions below. Please write your answers in the spaces provided.

A4. How many calories are in the WHOLE CONTAINER of this [FOOD]?

_______Calories

 Don’t know

A5. How many calories are in ONE SERVING of this [FOOD]?

_______Calories

 Don’t know

A6. How many grams of total fat are in the WHOLE CONTAINER of this [FOOD]?

_______Grams total fat

 Don’t know

A7. How many grams of total fat are in ONE SERVING of this [FOOD]?

_______Grams total fat

 Don’t know

A8. How many grams of dietary fiber are in the WHOLE CONTAINER of this [FOOD]?

_______Grams dietary fiber

 Don’t know

A9. How many grams of dietary fiber are in ONE SERVING of this [FOOD]?

_______Grams dietary fiber

 Don’t know

A10. How many servings of this [FOOD] would someone need to eat to get all of the Vitamin A that they need in a day?

_______Servings

 Don’t know

A11. How many servings of these chips would provide someone with the maximum amount of sodium someone should eat in a day?

_______Servings

 Don’t know

A12. For this set of questions, please tell us what you think about the Nutrition Facts label you see by using the scales provided to answer each question.

	Not at all 1	2	3	4	Very 5	Don’t know
How useful is this label to you personally?
How helpful is this label for determining the healthiness of the food?
How trustworthy is the information on this label?
How confusing is this label?
How helpful is this label for determining the number of calories PER SERVING in this food?
How helpful is this label for determining the number of calories PER ENTIRE CONTAINER?

TWO-PRODUCT TASK

Please take a moment to look at these two [insert “NEW” if this is the second task] Nutrition Facts labels.

Note that the label information you see in this study may or may not be the same as you would see at the grocery store.

[INSERT TWO FOOD LABELS SIDE-BY-SIDE, BEFORE subsequent instructions.]

Please answer the questions below based on what you can see on the Nutrition Facts labels shown on your screen.

B1. Based on what you can see on the labels, if you wanted to buy the healthier product, which of these two products would you select?

_______[FOOD] on the left is healthier

_______[FOOD] on the right is healthier

_______I can’t tell [GO to B1A]

B1A. [IF “I can’t tell”] You indicated that you couldn’t tell which of these products you would select. Which of the following best describes why you couldn’t tell?

Both foods seem equally unhealthy

Both foods seem equally healthy

______ Don’t know

Other (Please specify: _____________________________)

B2. Based on what you can see on the labels, if you wanted to buy the [FOOD] with the fewest calories PER CONTAINER, which of these two products would you select?

_______[FOOD] on the left is healthier

_______[FOOD] on the right is healthier

_______I can’t tell

B3. Based on what you can see on the labels, if you wanted to buy the [FOOD], with the fewest calories PER SERVING, which of these two products would you select?

_______[FOOD] on the left is healthier

_______[FOOD] on the right is heathier

_______I can’t tell

B4. For each nutrient listed below, tell us which product you think is healthier based on that specific nutrient, and not thinking about anything else. Please mark an answer for each nutrient.

	Food on left is healthier	Food on right is healthier	Both foods are about the same	Don’t know
Total Fat
Sodium
Sugars
Vitamin A
Fiber
Iron

AUXILIARY MEASURES

Consumption of and Familiarity with Types of Foods Included in the Study [ROTATE FOODS FOR ENTIRE SECTION]

D1. During the past 30 days, about how often did you BUY these types of foods? Please select one answer for each food. [ROTATE FOODS]

	Not at all	Less than once a week	Once a week	More than once a week	Don’t know
Chips
Frozen Entrees

D2. During the past 30 days, about how often did you EAT these types of foods? Please select one answer for each food. [ROTATE FOODS]

	Not at all	Less than once a week	Once a week	2-3 times a week	Every day or almost every day	Don’t know
Chips
Frozen Entrees

D3. How familiar are you with the average nutritional qualities of…

	Not at all familiar				Very familiar
	1	2	3	4	5	Don’t know
Chips
Frozen Entree

D4. How healthy or nutritious would you say each of these foods is in general compared to other types of foods you eat? On a scale of 1 to 5, where 1 means “not healthy” and 5 means “very healthy,” how healthy is ….

	Not healthy 1	2	3	4	Very healthy 5	Don’t know
Chips
Frozen Entree

D5. When shopping for [FOOD] at the store, how important to you is each of the factors listed below? Use a scale of 1 to 5, where 1 means “Not at all important” and 5 means “Very important.” Add don’t know

	Not at all important 1	2	3	4	Very important 5	Do not buy food	Don’t know
Price
Brand
Healthiness
Taste

Food Label Use

E1. When you BUY a food product for the first time, how often do you use the Nutrition Facts label?

_____Often

_____Sometimes

_____Rarely

_____Never [Skip E2]

_____Don’t know

E2. When deciding to buy a food product, how often, if at all, do you use the Nutrition Facts label in the following ways?

	Often	Sometimes	Rarely	Never	Don’t know
To help you decide which brand of a particular type of food to buy
To figure out how much of the food product you or your family should eat
To compare two different types of products to each other (e.g., soup vs. cereal)
To see if something said in advertising or on the package is actually true
To get a general idea of the nutritional content of the food
To see how high or low the food is in things like calories, salt, vitamins, or fat
To help you in meal planning

E3. How often do you use the Nutrition Facts label AFTER you have bought a food product?

_____ Often

_____Sometimes

_____Rarely

_____Never [Skip E4]

_____Don’t know

E4. AFTER you have bought a food product, how often, if at all, do you use the Nutrition Facts label in the following ways?

	Often	Sometimes	Rarely	Never	Don’t know
To figure out how much of the food product you or your family should eat
To compare two different types of products to each other (e.g., soup vs. cereal)
To see if something said in advertising or on the package is actually true
To get a general idea of the nutritional content of the food
To see how high or low the food is in things like calories, salt, vitamins, or fat
To help you in meal planning

E5. How much do you agree with each of the following statements? Please select one answer for each statement.

	Strongly disagree	Somewhat disagree	Somewhat agree	Strongly agree	Don’t know
I feel confident that I know how to use food labels to choose a nutritious diet.
The nutrition information on food labels is easy to understand.
Reading food labels takes more time than I can spare.
The nutrition information on food labels is useful to me.
Reading food labels makes it easier to choose foods.
When I use food labels, I make better food choices.
Using food labels to choose foods is better than just relying on my own knowledge about what is in them.

E6. Think about the “serving size” on a food label. What does serving size mean to you? Serving size is… (Mark all that apply)

_____The amount of this food that people should eat

_____The amount of this food that people usually eat

_____Something that makes it easier to compare foods

Other (Please specify: _____________________________)

_____Don’t know

Dietary Awareness, Knowledge, and Interests

F1. Would you say your health in general is:

___Excellent

___Very good

___Good

___Fair

___Poor

___Don’t know

___Prefer not to answer

F2. Do you consider yourself to be overweight, underweight, or about the right weight?

____Overweight

____Underweight

____About the right weight

____ Don’t know

____Prefer not to answer

F3. During the past 3 months, have you been trying to limit or cut down on these things in your diet?

	Yes	No	Don’t know	Prefer not to answer
Fat
Carbs or carbohydrates
Sodium or salt
Calories
Cholesterol
Sugar

F4. About how many calories do you think a person of your age, gender, and physical activity needs to consume in a day to maintain your weight?

___Less than 500 calories

___500-1000 calories

___1001-1500 calories

___1501-2000 calories

___2001-2500 calories

___2501-3000 calories

___More than 3000 calories

___Don’t know

Section G. Cosmetics

We would also like to ask you a few questions about cosmetics. By cosmetics we mean toothpaste, shampoo, deodorant, skin moisturizer , perfumes, lipsticks, fingernail polishes, eye and facial makeup preparations, permanent waves, hair colors.

G1. Have you ever had a bad reaction to a cosmetic [Include allergic reactions]?

        _____Yes    [go to G2]

        _____No [go to G4]

_____Don't know [go to G4]

 

G2. Did you report the bad reaction?

       _____Yes    [go to G3]

        _____No [go to F1]

_____Don’t know [go to G3c]

 

G3. Where did you report the bad reaction? (You may select one or more option.)

      _____My state or local health authority [go to G3b]

      _____The manufacturer [go to G3b]

      _____My healthcare provider [go to G3b]

      _____The Food and Drug Administration [go to G3b]

     _____Poison Control Center [go to G3b]

      _____The Consumer Product Safety Commission [go to G3b]

_____The store where I bought it [got to G3b]

      _____Other (please specify): ___________________ [go to G3b]

_____Don’t know   [go to F1]       

 G3b. How did you report it?

____By phone

____By mail

____By email or at a website

____In person

G3c. Why did you not report it? (Open ended)

[All answers go to F1]

G4. If you had a bad reaction to a cosmetic, where would you report it? (You may select one or more answer.)

____My state or local health authority

____The manufacturer [go to G5]

____My healthcare provider [go to G5]

____The Food and Drug Administration [go to G5]

____Poison Control Center [go to G5]

____The Consumer Product Safety Commission [go to G5]

____The store where I bought it [go to G5]

____Other (please specify): __________________ [go to G5]

____I would not report it [go to H1]

____Don’t know   [go to H1]       

G5. How would you report it?        

     ____ By phone

    ____ By mail 

     ____ By email or at a website 

____ In person

___ Don’t know

____ Other (please specify): ____________________________

Section H. Demographics.

The next few questions may seem a bit personal, but we need this information because this survey is about nutrition and health.

H1. How tall are you without shoes? Please enter a number in both “feet” and “inches” or select “prefer not to answer.”

Feet _____ Inches ____

• Prefer not to answer

• Don’t know

H2. How much do you weigh without shoes? Please enter a number in pounds.

Pounds ______

• Prefer not to answer

• Don’t know

H2b. Have you ever been told by a doctor or other healthcare professional that you have any of the following health conditions? We don’t need to know which condition, just whether you have ANY of them -- high blood pressure, diabetes, high cholesterol, heart disease, obesity, overweight, or cancer.

Yes

No

Prefer not to answer

H3. What is your sex?

_____Female

_____Male

Prefer not to answer

H4. What is the highest grade or level of school you have completed? Please select one.

	Yes
Less than 9th grade
9th to 12th grade, NO DIPLOMA
High school graduate – DIPLOMA or GED
Some college or Associate degree
Bachelor’s degree
Graduate or professional degree
Prefer not to answer

H5. What year were you born?

__________

Prefer not to answer

H6. Are you of Hispanic or Latino origin? Please select one.

_____Yes

_____No

_____Prefer not to answer

H7. What race do you consider yourself to be? Please select one or more.

_____American Indian or Alaska Native

_____Asian

_____Black or African American

_____Native Hawaiian or other Pacific Islander

_____White

_____Other

_____Prefer not to answer

You have reached the end of the survey. Thank you very much for your participation in this research.

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