English and Spanish Bodywork Program comparison group participant-Follow-up

Multi-Component Evaluation of the Bodyworks Program

0990-BodyWorks_Full Evaluation_child follow-up_ENG

English and Spanish Bodywork Program comparison group participant-Follow-up

OMB: 0990-0385

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Form Approved OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

Child Follow-up Survey

This survey is important. It asks about the BodyWorks program, your health and your eating and physical activity habits. By taking this survey, you will help us make BodyWorks better. It will take about 20 minutes. Please read each question before you write your answer. Pick one answer for each question, unless the directions say you can pick more than one. You can skip a question that you do not want to answer. Circle the question number to let us know you skipped it on purpose. This is NOT a test! Be as honest as you can. Your answers are private.

Please write the first and last initials of the parent or caregiver who came with you to this program.

[Ex: For Jane Smith, it is J.S. For Jane Doe-Smith, it is J.D.]


__________


__________

Parent’s First Initial

Parent’s Last Initial

What is your DATE of BIRTH?

[Ex: Write 05/22/95 if your birthday is May 22, 1995]


If you are a twin, tell us if you are the older or younger twin

/ /

MM DD YY


Older twin

Younger twin


Where was your BodyWorks program? Site 1 Site 2 Site 3 [Sites will be entered when chosen]



1. Right now, how do you feel about making changes to your eating habits?

I have not thought about making any changes.

I plan to make changes later, maybe in 6 months.

I want to make changes soon, maybe in the next month.

I am making changes right now, but this has been for less than 6 months.

I have made changes and have kept up with them for 6 months or longer.

2. How much do you want to make changes to your eating habits?

Not at all

Very little

Some

A lot

3. Right now, how do you feel about making changes to your exercise habits?

I have not thought about making any changes.

I plan to make changes in the future, maybe in 6 months.

I want to make changes soon, maybe in the next month.

I am making changes right now, but this has been for less than 6 months.

I have made changes and have kept up with them for 6 months or longer

4. How much do you want to make changes to your exercise habits?

Not at all

Very little

Some

A lot


5a. How important to YOU is…

Not At All Important

Not Very Important

Important

Very Important

  1. Eating healthy foods like fruits, vegetables, whole grains, milk, and meat and beans?

  1. Exercising for one hour every day?

  1. Setting goals to improve your eating and physical activity habits?

  1. Writing in a journal about your eating and physical activity habits?

  1. Helping your parent or caregiver plan, shop for, or make healthy meals and snacks?

  1. Preventing diseases that happen later in life, like heart disease, diabetes, and osteoporosis (a disease that causes bones to break more easily)?


5b. How important is it to your PARENT/CAREGIVER that you

Not At All Important

Not Very Important

Important

Very Important

  1. Eat a healthy diet?

  1. Exercise each day for one hour?

  1. Set goals to improve your eating and physical activity habits?

  1. Write in a journal about your eating and physical activity habits?

  1. Help plan, shop for, or make healthy meals and snacks?


6. Do you want to do what your parents/caregivers want you to do when it comes to…

No, Not At All

No, Not Really

Yes, A Little

Yes, For Sure

  1. Healthy eating?

  1. Physical activity?

  1. Setting goals to improve your eating and physical activity habits?

  1. Writing in a journal about your eating and physical activity habits?

  1. Helping plan, shop for, or make healthy meals and snacks?


7. Do you think you can …

No, Not At All

No, Not Really

Yes, A Little

Yes, For Sure

  1. Talk with your family about how you can eat healthier foods or get more physical activity?

  1. Help plan for, shop, or make healthy meals each week?

  1. Use nutrition facts labels on packages to pick healthy foods?

  1. Choose healthy foods and drinks at home?

  1. Choose healthy foods and drinks at restaurants, including fast food restaurants?

  1. Plan what physical activities you will do for the week?

  1. Exercise for one hour every day?

  1. Exercise even if there are barriers, like if you are too tired or very busy?

  1. Choose to be active instead of watching TV or sitting at the computer?

  1. Do bone-strengthening physical activities (running or jumping rope)?


8. The most important time in life for building strong bones is when you are a/an…

Baby or young child (ages 0-8)

Preteen or teen (ages 9-18)

Young adult (ages 19-29)

Adult (ages 30 to 54)

Older adult (age 55+)

Don’t know

9. A “serving size” is the amount of food you choose to eat for a meal or a snack.

True False Don’t know

10. A “portion” is included on a nutrition facts label and helps you see how many calories are in a serving of food.

True False Don’t know

11. The dangers of unhealthy dieting can be: (Choose one or more.)

Not getting enough nutrients to grow and develop

More risk for weaker bones and osteoporosis later in life

More risk for an eating disorder

Don’t know

12. Which are whole grain foods? (Choose one or more.)

Brown rice

Cheese

Apple juice

Oatmeal

Don’t know

13. Which sandwich has less fat?

Turkey sandwich with mustard

Tuna salad sandwich

Don’t know

14. How can physical activity help you? (Choose one or more.)

Helps you control your weight

Helps you feel less stressed

Makes you more confident

Decreases your vitamin B levels

Don’t know

15. You are taking a walk. You are breaking a sweat, but you can still talk to your friend. This activity is:

Light

Moderate

Vigorous

Don’t know


16. Tell us about the past 7 days. On how many days did you…

0

Days

1-2

Day

3-4

Days

5-7

Days

  1. Write in a journal your eating and physical activity habits?

  1. Work toward goals you set to eat healthy foods and be physically active?

  1. Help plan healthy meals and snacks?

  1. Help shop for healthy foods and drinks?

  1. Help make healthy meals or snacks?

  1. Eat a healthy breakfast?

  1. Take a healthy bag lunch to school?

  1. Eat a meal together with your family?

  1. Exercise for one hour?

  1. Exercise with your parent or caregiver?

  1. Do bone-strengthening exercises (like walking or jumping rope)?

  1. Choose to be active instead of watching TV and/or sitting at the computer?


17. Think about the past 7 days. Did your parent/caregiver encourage you to…

No

Yes

  1. Eat healthy foods like fruits, vegetables, whole grains, milk, and meats and beans?

  1. Exercise each day for one hour?

  1. Set goals to improve your eating and physical activity habits?

  1. Write in a journal about your eating and physical activity habits?

  1. Help plan, shop for, or make healthy meals and snacks?


18. Think about what you eat on an AVERAGE DAY. How many times do you eat or drink…

0 Times

1

Time

2 Times

3 Times

4 Times

5+ Times

  1. Milk or milk products (yogurt, cheese) or milk substitutes (like soy milk or rice milk)?

  1. Soda or pop?

  1. Fruits (including 100% fruit juice)?

  1. Meat or beans (beef, fish, chicken, tofu, egg, peanut butter, cooked beans, nuts, seeds)?

  1. Chips or French fries?

  1. Vegetables (including those in soup, stir fry, gumbo, stew, casserole, taco, or omelets)?

  1. Candy, cookies, cake, or other sweets?

  1. Grains (bread, cereal, rice, pasta)?


19. During the next month, I plan to…

Disagree

a lot

Disagree

Agree

Agree

a lot

  1. Make healthy food choices.

  1. Exercise more often, including bone-strengthening physical activities.

  1. Exercise more often with my parent or caregiver.

  1. Set/work toward nutrition and physical activity goals.

  1. Help plan, shop for, or prepare healthy meals.

  1. Eat a healthy breakfast every day.

  1. Eat meals together with my family.

  1. Take a healthy bag lunch to school.


20a. In the past 8 weeks, did you go to any education programs about healthy eating or physical activity outside of school?


No Yes

20b. If you checked “yes,” please describe the program:




You’ve reached the end. Thank you for your help!

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 control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.



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File Created2021-02-01

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