HCS_SSA_ATTACH 15_OBSERVATIONS PROTOCOLS_SEPTEMBER 2011 FINAL for OMB

SSA Attachment 15

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

COMMUNITY OBSERVATIONS AND ENVIRONMENTAL

ASSESSMENTS PROTOCOL

The following document contains the community observations and environmental assessments for the HCS. This includes the modified and full windshield surveys of the household’s immediate neighborhood, interviews with additional school administrators/personnel, community key informants, GIS data, and direct observations of schools and communities to collect program/policy and environmental data. These community and environmental assessments will be conducted in all 279 communities during the initial visit to the community; more detailed community and environmental assessments will be conducted in the RIPA communities when the Battelle community liaison returns to these communities three months after the baseline assessment; furthermore, the school environmental assessments will be repeated in the RIPA communities during the follow-up in-person assessment visit.

“Windshield Survey”

In all 279 communities, at the time of the (initial) Standard Protocol home visit, the EMSI field interviewers will complete a five-item modified windshield survey prior to entering the home. EMSI field interviewers will rate features of the social and physical environment on the street segment associated with each child’s home address. A street segment is defined as the street in front of the home, from intersection to intersection, not to exceed 0.5 miles. In the instances where the street segment exceeds 0.5 miles, the EMSI field interviewers will be instructed to consider the street segment that is contained within 0.25 miles from the home in either direction or to the nearest intersection, whichever is closer.

For children who receive the Enhanced Protocol, the modified windshied survey will be conducted during the first home visit, and the full windshield survey (i.e., Neighborhood Attributes Inventory [NAI]) will be completed at the second home visit approximately one week later. The NAI instrument assesses the physical and social environment of the street segment on which a child lives and consists of three scales: Physical Incivilities, Territoriality, and Play and Social Spaces. The Physical Incivilities scale includes items such as vacant residencies, litter, graffiti, and building conditions. Territoriality scale includes items such as crime watch signs, security bars on homes, and homes with decorations. The Play and Social Space scale includes the proportion of homes with a yard, porches, presence of parks, speed limit on street, and sidewalks. In addition, the inventory assesses non-residential land use (i.e., mixed land use).

A paper form of the modified five-item and full windshield survey, included in this attachment, will be completed when the EMSI field interviewer arrives at the child’s home and entered into the study database following the home visit. This will be done at baseline and at follow up during the in person assessments in the RIPA communities. GPS coordinates will also be obtained for each participant’s household to match to GIS data.

Nutritional Environment

Baseline observational assessments of the nutritional environment will be conducted in up to four randomly selected schools (two elementary and two middle schools) per community. A member of the school’s food service staff will complete a brief self-administered questionnaire , and, along with the Battelle community liaison, will observe the school’s lunch period and complete an observation form (the protocol for the food service personnel is provided in SSA Attachment 16). In addition, questions will be asked of the principals of the schools selected for observations during the key informant interview. The protocol for the school principals is provided in SSA Attachment 14, as part of the key informant interview protocol.

The principals of the schools that were randomly selected for observations, if they consented to be a key informant, will be sent a link to the food service staff questionnaire and lunch observation form during the follow-up period and asked to forward the link to the appropriate food service person for completion.

GIS mapping and analyses will also be conducted to characterize the community food environment at baseline and retrospectively 10 years prior to coincide to the extent possible with baseline and endpoint BMI data collection. The GIS data will include the density of various types of retail food establishments in the target community as well as their proximity to schools in the target area to characterize the community nutrition environment. In the RIPA communities, the community liaison will return to the community within three months of their baseline visit to conduct limited ground-truthing of the GIS data that were collected. For example, for the nutrition environment, this may entail verifying the existence of commercial food venues identified in the GIS data.

Physical Activity Environment

Baseline observational assessments of the physical activity environment will be conducted in up to four randomly selected schools (two elementary and two middle schools) per community. The Battelle community liaison will interview a member of the physical education staff at the school (see SSA Attachment 17), and will also observe the school’s physical activity resources using the Physical Activity Resource Assessment (School PARA) form (included in this attachment). The School PARA will be conducted for both indoor and outdoor features of the environment related to physical activity. This form characterizes the features, amenities, and incivilities of the physical activity environment(s) in the school, the hours, availability, and capacity of the facilities, and size and cost of use of these environments.

In addition, questions will be asked of the principals of the schools selected for observations during the key informant interview. Furthermore, key informants who are particularly knowledgeable about parks and recreation and other physical activity resources in the community will answer additional questions The protocol for the school principals and key informants knowledgeable about physical activitiy resources in the community is provided in SSA Attachment 14, as part of the key informant interview protocol.

Geographic information system (GIS) mapping and analyses conducted at baseline will also provide information related to the physical activity environment. When the Battelle community liaison returns to the community within three months of their baseline visit in the RIPA communities, s/he will also conduct limited ground-truthing of the physical activity GIS data. For example, for the physical activity environment, this may entail verifying the existence of parks. The physical activity environment will be further characterized in the RIPA communities by the completion of the full PARA (included in this attachment) for schools, parks, and trails identified within the community.

HEALTHY COMMUNITIES STUDY

MODIFIED WINDSHIELD SURVEY

There is little to no public reporting burden of this collection of information as it is completed by research staff. 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.

	HOUSEHOLD ID#:		DATE:
To be completed by EMSI research staff: COMPLETE THE FOLLOWING FORM ON THE STREET SEGMENT ASSOCIATED WITH THE CHILD’S HOME ADDRESS. A STREET SEGMENT IS DEFINED AS THE STREET IN FRONT OF THE HOME, FROM INTERSECTION TO INTERSECTION, NOT TO EXCEED 0.5 MILES. OBSERVE THE STREET SEGMENT WHILE DRIVING TO THE HOME. FILL OUT THIS FORM WHILE PARKED OUTSIDE OF THE PARTICIPANT’S HOME.
1.	OVERALL CONDITION OF MOST RESIDENTIAL UNITS				EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4 MIXED CONDITION 5
2.	ANY BURNED, BOARDED UP, OR ABANDONED RESIDENTIAL UNITS?				YES 1 NO 2
3.	AMOUNT OF LITTER				NONE…(SKIP TO Q4) 0 A LITTLE 1 A MODERATE AMOUNT 2 A CONSIDERABLE AMOUNT 3
	TYPE OF LITTER (CODE ALL THAT APPLY)				NONALCOHOLIC CANS/BOTTLES/PAPER 1 ALCOHOLIC CANS/BOTTLES 2 LARGE ITEMS (TIRES, FURNITURE, APPLIANCES, CARS) 3 OTHER LITTER 4
4.	TYPE OF STREET SEGMENT (CODE ALL THAT APPLY)				MAJOR THOROUGHFARE/BUSY STREET 1 MODERATELY BUSY THOROUGHFARE 2 SIDE STREET 3 DEAD-END STREET 4 ONE WAY STREET 5 CUL-DE-SAC STREET 6
5.	PRESENCE OF SIDEWALKS				NONE…(END SURVEY) 0 SOME OF THE SEGMENT 1 ALL OF THE SEGMENT 2
	IS THE SIDEWALK CONDUCIVE TO BEING ACTIVE (RIDING A BIKE, SKATEBOARDING)?				YES 1 IN MOST PLACES 2 IN SOME BUT NOT ALL PLACES 3

HEALTHY COMMUNITIES STUDY FULL WINDSHIELD SURVEY There is little to no public reporting burden of this collection of information as it is completed by research staff. 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.
	HOUSEHOLD ID#:				DATE:
To be completed by EMSI research staff: COMPLETE THE FOLLOWING FORM ON THE STREET SEGMENT ASSOCIATED WITH THE CHILD’S HOME ADDRESS. A STREET SEGMENT IS DEFINED AS THE STREET IN FRONT OF THE HOME, FROM INTERSECTION TO INTERSECTION, NOT TO EXCEED 0.5 MILES. OBSERVE THE STREET SEGMENT WHILE DRIVING TO THE HOME. FILL OUT THIS FORM WHILE PARKED OUTSIDE OF THE PARTICIPANT’S HOME. FOR EACH SECTION, COMPLETE THE COLUMN UNDER SIDE A FOR ONE SIDE OF THE STREET AND THE COLUMN UNDER SIDE B FOR THE OTHER SIDE OF THE STREET.
SECTION A: NEIGHBORHOOD PHYSICAL CONDITIONS
					SIDE A	SIDE B
A1.		NUMBER OF HOUSING UNITS			#
A2.		NUMBER WITH FRONT YARD			#
A3.		NUMBER WITH PORCHES			#
A4.		NUMBER WITH DECORATION			#
A5.		NUMBER WITH BORDER (FENCES/ SHRUBS)			#...(IF <1, SKIP TO A7)
A6.		AVERAGE HEIGHT OF BORDERS			BELOW SHOULDER LEVEL 1 ABOVE SHOULDER LEVEL 2 MIXED 3	1 2 3
A7.		NUMBER SALE/RENT SIGNS			#
A8.		NUMBER SECURITY BARS/GRATINGS			#
A9.		NUMBER OF BURNED, BOARDED UP OR ABANDONED			#
A10.		TYPES OF RESIDENTIAL HOUSING (CODE ALL THAT APPLY)			NONE…(SKIP TO SECTION B) 0 SINGLE FAMILY DETACHED DWELLINGS 1 TRAILER HOME/MOBILE HOME 2 MULTIPLE OCCUPANCY (2-6 UNITS) 3 APARTMENT BUILDING (>7 UNITS) 4 HOUSING AUTHORITY PROJECTS 5 NEW CONSTRUCTION 6 RENOVATION 7	0 1 2 3 4 5 6 7
					SIDE A	SIDE B
A11.		MAIN TYPE OF RESIDENTIAL HOUSING (CODE MORE THAN ONE IF NECESSARY)			SINGLE FAMILY DETACHED DWELLINGS 1 TRAILER HOME/MOBILE HOME 2 MULTIPLE OCCUPANCY (2-6 UNITS) 3 APARTMENT BUILDING (>7 UNITS) 4 HOUSING AUTHORITY PROJECTS 5 NEW CONSTRUCTION 6 RENOVATION 7	1 2 3 4 5 6 7
A12.		OVERALL CONDITION OF MOST RESIDENTIAL UNITS			EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4 MIXED CONDITION 5	1 2 3 4 5
A13.		OVERALL CONDITION OF RESIDENT-KEPT GROUNDS			NOT APPLICABLE 0 EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4 MIXED CONDITIONS (EXTREME DIFFERENCES) 5	0 1 2 3 4 5
A14.		INDICATION OF NEIGHBORHOOD/BLOCK UNIFORMITY			NO 0 YES 1	0 1
SECTION B: PUBLIC SPACE
B1.		AMOUNT OF LITTER			NONE…(SKIP TO B3) 0 A LITTLE 1 A MODERATE AMOUNT 2 A CONSIDERABLE AMOUNT 3	0 1 2 3
B2.		TYPE OF LITTER (CODE ALL THAT APPLY)			PAPER, CANS/BOTTLES NONALCOHOLIC 1 CAN/BOTTLES ALCOHOLIC 2 DRUG PARAPHERNALIA 3 CLOTHING ITEMS 4 FURNITURE 5 TIRES 6 APPLICANCES (SMALL) 7 APPLIANCES (LARGE) 8 ABANDONED VEHICLES 9 OTHER: ______________________ 10	1 2 3 4 5 6 7 8 9 10
B3.		AMOUNT OF GRAFFITI			NONE 0 A LITTLE 1 A MODERATE AMOUNT 2 A CONSIDERABLE AMOUNT 3	0 1 2 3
					SIDE A	SIDE B
B4.		VISIBLE SIGNS (CODE ALL THAT APPLY)			NONE 0 NEIGHBORHOOD SIGN 1 NEIGHBORHOOD /COMMUNITY WATCH SIGN 2 NO TRESPASSING SIGN/NO SOLICITATION/PRIVATE PROPERTY 3 PUBLIC TRANSPORTATION STOPS 4 COMMERCIAL ADVERTISING 5 POLITICAL EVENTS/CAMPAIGNS 6 NEIGHBORHOOD, SOCIAL, CULTURAL EVENTS 7 DRUG FREE ZONE 8 HOME-BASED BUSINESS 9 NO DUMPING 10 BEWARE OF DOG 11 OTHER ______________________ 12	0 1 2 3 4 5 6 7 8 9 10 11 12
B5.		PARKING OR TRAFFIC SIGNS (CODE ALL THAT APPLY)			NONE 0 SPEED LIMIT 1 RECORD SPEED LIMIT STOP SIGN/STOP LIGHT 2 NO PARKING/STOPPING 3 SCHOOL ZONE 4 CHILDREN PLAYING/WATCH FOR CHILDREN 5 STREET CROSSING BUTTON/ CROSSWALK 6 STOP SIGN AHEAD 7 BIKE ROUTE 8 OTHER ______________________ 9	0 1 2 3 4 5 6 7 8 9
B6.		PRESENCE OF STREET LAMPS			NONE 0 SOME 1 ENOUGH TO PROVIDE LIGHT TO ALL OF THE SEGMENT 2	0 1 2
B7.		PRESENCE OF SIDEWALKS			NONE…(SKIP TO B9) 0 SOME OF THE SEGMENT 1 ALL OF THE SEGMENT 2	0 1 2
B8.		IS THE SIDEWALK CONDUCIVE TO BEING ACTIVE (RIDING A BIKE, SKATEBOARDING)?			YES 1 IN MOST PLACES 2 IN SOME BUT NOT ALL PLACES 3	1 2 3
B9.		TYPE OF STREET SEGMENT (CODE ALL THAT APPLY)			MAJOR THOROUGHFARE/ BUSY STREET 1 MODERATELY BUSY THOROUGHFARE 2 SIDE STREET 3 DEAD-END STREET 4 ONE WAY STREET 5 CUL-DE-SAC STREET 6	1 2 3 4 5 6
					SIDE A	SIDE B
B10.		NUMBER OF LANES ACROSS ROAD			#
B11.		GENERAL CONDITION OF PUBLIC SPACES			EXCELLENT 1 GOOD 2 FAIR 3 POOR 4 MIXED CONDITIONS 5	1 2 3 4 5
SECTION C: SOCIAL INTERACTIONS
C1.		NUMBER OF PEOPLE VISIBLE (ADULTS + CHILDREN)			#...(IF 0, SKIP TO SECTION D)
C2.		NUMBER OF CHILDREN UNDER 12 YEARS OLD			#
C3.		ADULT ACTIVITY (CODE ALL THAT APPLY)			IF NO ADULTS PRESENT 0 WALKING 1 SOCIALIZING (TALKING WITH NEIGHBORS) 2 SOCIALIZING IN MIXED RACIAL GROUPS 3 HOME REPAIR, LANDSCAPING, OR CAR CARE 4 SITTING/STANDING ON PORCH OR STOOP 5 SUPERVISING CHILDREN 6 PATRONIZING BUSINESS ESTABLISHMENTS 7 STANDING ON THE SIDEWALK 8 SITTING/STANDING AT THE BUS STOP 9 GETTING INTO OR OUT OF VEHICLES 10 WALKING A DOG 11 CONDUCTING HOME-BASED VENDING 12 RECREATIONAL ACTIVITY (EG, JOGGING) 13 SMOKING 14 DRINKING ALCOHOL 15 DRUG RELATED ACTIVITY 16 SEX TRADE 17 FIGHTING 18 OTHER ______________________ 19	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

			SIDE A	SIDE B
C4.	CHILDREN’S ACTIVITIES (CODE ALL THAT APPLY) FOR CHILDREN 12 AND UNDER		SITTING OR STANDING ON PORCH OR FRONT YARD 1 PLAYING ON THE PORCH OR FRONT YARD 2 SITTING, STANDING OR PLAYING IN THE STREET 3 SITTING STANDING OR PLAYING IN A VACANT LOT 4 SITTING STANDING OR PLAYING ON THE SIDEWALK 5 PLAYING AT PARK OR PLAY GROUND 6 OTHER _________________________ 7	1 2 3 4 5 6 7
C5.	PROPORTION OF CHILDREN UNDER ADULT SUPERVISION		NONE 0 LESS THAN ONE THIRD 1 ONE THIRD TO ONE HALF 2 MORE THAN HALF 3	0 1 2 3
C6.	PEOPLE FROM MORE THAN ONE RACIAL GROUP		NO 0 YES 1	0 1
C7.	REACTION OF PEOPLE TO RATERS (CODE ALL THAT APPLY)		NONE OR VERY LITTLE NOTICE TAKEN 0 GLANCES CURIOSITY, WAVE OR HELLO 1 BLATANT SPECULATIVE STARES 2 RESIDENTS ASK RATERS WHAT THEY ARE DOING 3 PEOPLE TELLING RATERS WHAT TO DO FOR NEIGHBORHOOD 4	0 1 2 3 4
C8.	NONRESIDENTIAL VISITORS (CODE ALL THAT APPLY)		THERE ARE NONE 0 MORMONS OR OTHER RELIGIOUS BASED VISITS 1 MOBILE VENDORS/FOOD PEDDLERS 2 CIVIC/SOCIAL SERVICE AGENTS 3 POLICE OFFICERS ON FOOT/VEHICLE/HORSE 4 UTILITY/REPAIR/DELIVERY PEOPLE 5 PEOPLE PASSING THROUGH 6 OTHERS _______________________ 7	0 1 2 3 4 5 6 7
SECTION D: NONRESIDENTIAL LAND USE TALLY SHEET
D1.	BUSINESS/INDUSTRY		NO…(SKIP TO D2) 0 YES 1	0 1
	MANUFACTURING LIGHT		NO…(SKIP TO D1b.) 0 YES… 1	0 1
	MANUFACTURING HEAVY		NO…(SKIP TO D1c.) 0 YES… 1	0 1
			SIDE A	SIDE B
	PROFESSIONAL OFFICES		NO…(SKIP TO D1d.) 0 YES… 1	0 1
	WAREHOUSE		NO…(SKIP TO D2.) 0 YES… 1	0 1
D2.	COUNTY/PUBLIC SERVICES/UTILITIES		NO…(SKIP TO D3) 0 YES 1	0 1
	CRIMINAL JUSTICE FACILITIES		NO…(SKIP TO D2b.) 0 YES… 1	0 1
	EMPLOYMENT OFFICES		NO…(SKIP TO D2c.) 0 YES… 1	0 1
	FIRE STATION		NO…(SKIP TO D2d.) 0 YES… 1	0 1
	PARKING LOT		NO…(SKIP TO D2e.) 0 YES… 1	0 1
	POLICE STATION		NO…(SKIP TO D2f.) 0 YES… 1	0 1
	POLITICAL/COMMUNITY/CIVIC		NO…(SKIP TO D2g.) 0 YES… 1	0 1
	SOCIAL SERVICE, WELFARE OFFICES		NO…(SKIP TO D2h.) 0 YES… 1	0 1
	UTILITY COMPANY (E.G., GAS)		NO…(SKIP TO D3.) 0 YES… 1	0 1
D3.	FOOD		NO…(SKIP TO D4) 0 YES 1	0 1
	CONVENIENCE STORES		NO…(SKIP TO D3b.) 0 YES… 1	0 1
	FAST FOOD/TAKE OUT PLACES		NO…(SKIP TO D3c.) 0 YES… 1	0 1
	RESTAURANTS		NO…(SKIP TO D3d.) 0 YES… 1	0 1
	SUPERMARKET/ GROCERY STORES		NO…(SKIP TO D4.) 0 YES… 1	0 1
D4.	HEALTHCARE		NO…(SKIP TO D5) 0 YES 1	0 1
	DRUG STORES/PHARMACIES		NO…(SKIP TO D4b.) 0 YES… 1	0 1
	HEALTH CLINIC		NO…(SKIP TO D4c.) 0 YES… 1	0 1
	HOSPITALS		NO…(SKIP TO D4d.) 0 YES… 1	0 1
D6.	PRIVATE SERVICES		NO…(SKIP TO D7) 0 YES 1	0 1
	AUTOMOBILE REPAIR/BODY SHOP		NO…(SKIP TO D6b.) 0 YES… 1	0 1
			SIDE A	SIDE B
	BANKS		NO…(SKIP TO D6c.) 0 YES… 1	0 1
	BARBER SHOP OR BEAUTY SALON		NO…(SKIP TO D6d.) 0 YES… 1	0 1
	BUSINESS SERVICES-PRINTING/COPYING		NO…(SKIP TO D6e.) 0 YES… 1	0 1
	CHECK CASHING SERVICE		NO…(SKIP TO D6f.) 0 YES… 1	0 1
	DRY CLEANING/ TAILORING/ LAUNDROMAT		NO…(SKIP TO D6g.) 0 YES… 1	0 1
	GASOLINE STATION		NO…(SKIP TO D6h.) 0 YES… 1	0 1
	REAL ESTATE OFFICE		NO…(SKIP TO D6i.) 0 YES… 1	0 1
	TRAVEL AGENTS		NO…(SKIP TO D7.) 0 YES… 1	0 1
D7.	RECREATION		NO…(SKIP TO D8) 0 YES 1	0 1
	BARS		NO…(SKIP TO D7b.) 0 YES… 1	0 1
	MOVIE THEATER		NO…(SKIP TO D7c.) 0 YES… 1	0 1
	RECREATIONAL SERVICE		NO…(SKIP TO D7d.) 0 YES… 1	0 1
	SEX ENTERTAINMENT SHOPS		NO…(SKIP TO D7e.) 0 YES… 1	0 1
	VIDEO GAMES/POOL/BOWLING		NO…(SKIP TO D8.) 0 YES… 1	0 1
D8.	RELIGIOUS		NO…(SKIP TO D9) 0 YES 1	0 1
	CEMETERY		NO…(SKIP TO D8b.) 0 YES… 1	0 1
	CHURCH/RELIGIOUS CENTER		NO…(SKIP TO D8c.) 0 YES… 1	0 1
	RELIGIOUS STORE		NO…(SKIP TO D8d.) 0 YES… 1	0 1
	FUNERAL HOME		NO…(SKIP TO D9.) 0 YES… 1	0 1
D9.	USED GOOD SALES		NO…(SKIP TO D10.) 0 YES 1	0 1
	AUTOMOBILE SALES/RENTAL USED		NO…(SKIP TO D9b.) 0 YES… 1	0 1
	FURNITURE STORE USED		NO…(SKIP TO D9c.) 0 YES… 1	0 1
			SIDE A	SIDE B
	PAWN SHOP		NO…(SKIP TO D9d.) 0 YES… 1	0 1
	SECOND HAND STORES		NO…(SKIP TO D10.) 0 YES… 1	0 1
D10.	RETAIL/SALES		NO…(SKIP TO D11.) 0 YES 1	0 1
	APPLIANCE SALES, RENTAL, REPAIR		NO…(SKIP TO D10b.) 0 YES… 1	0 1
	AUTOMOBILE SALES/RENTAL NEW		NO…(SKIP TO D10c.) 0 YES… 1	0 1
	CLOTHING STORES		NO…(SKIP TO D10d.) 0 YES… 1	0 1
	ELECTRONIC STORES		NO…(SKIP TO D10e.) 0 YES… 1	0 1
	FURNITURE STORES NEW		NO…(SKIP TO D10f.) 0 YES… 1	0 1
	HOME REPAIR/ HARDWARE/LUMBER		NO…(SKIP TO D10g.) 0 YES… 1	0 1
	LIQUOR STORES		NO…(SKIP TO D10h.) 0 YES… 1	0 1
	SPECIALTY RETAILERS		NO…(SKIP TO D10i.) 0 YES… 1	0 1
	VARIETY STORES		NO…(SKIP TO D11.) 0 YES… 1	0 1
D11.	SCHOOLS/CHILDCARE		NO…(SKIP TO D12.) 0 YES 1	0 1
	DAY CARE CENTERS		NO…(SKIP TO D11b.) 0 YES… 1	0 1
	PUBLIC SCHOOL (K-12)		NO…(SKIP TO D11c.) 0 YES… 1	0 1
	TECHNICAL SCHOOL		NO…(SKIP TO D11d.) 0 YES… 1	0 1
	COLLEGES		NO…(SKIP TO D11e.) 0 YES… 1	0 1
	PRIVATE PAROCHIAL SCHOOL		NO…(SKIP TO D11f.) 0 YES… 1	0 1
	PRIVATE NON-PAROCHIAL SCHOOL		NO…(SKIP TO D12.) 0 YES… 1	0 1
D12.	PHYSICAL ACTIVITY FACILITIES		NO…(SKIP TO D13.) 0 YES 1	0 1
	GOLF COURSE		NO…(SKIP TO D12b.) 0 YES… 1	0 1
	SWIMMING POOL		NO…(SKIP TO D12c.) 0 YES… 1	0 1
			SIDE A	SIDE B
	GYM		NO…(SKIP TO D12d.) 0 YES… 1	0 1
	TENNIS COURTS		NO…(SKIP TO D12e.) 0 YES… 1	0 1
	COUNTRY CLUB		NO…(SKIP TO D12f.) 0 YES… 1	0 1
	BIKE PATH/WALKING TRAIL		NO…(SKIP TO D13.) 0 YES… 1	0 1
D13.	OTHER (INCLUDE FARM LAND HERE)		NO 0 YES… 1	0 1
D14.	IS COMMERCIAL, NONRESIDENTIAL LAND USE PRESENT?		NO…(SKIP TO D18.) 0 YES 1 NEW CONSTRUCTION 2 RENOVATION 3	0 1 2 3
D15.	OVERALL CONDITION OF MOST OF THE BUILDINGS		EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4 MIXED CONDITIONS (EXTREME DIFFERENCES) 5	1 2 3 4 5
D16.	PROPORTION WITH SECURITY BARS/GRATINGS		NONE 0 LESS THAN 1/3 1 ONE THIRD TO ONE HALF 2 MORE THAN HALF 3	0 1 2 3
D17.	PROPORTION OF BURNED, BOARDED UP, OR ABANDONED		NONE 0 LESS THAN 1/3 1 ONE THIRD TO ONE HALF 2 MORE THAN HALF 3	0 1 2 3
D18.	PROPORTION OF THE LAND THAT IS VACANT/UNDER-DEVELOPED		NONE…(SKIP TO D20.) 0 LESS THAN 1/3 1 ONE THIRD TO ONE HALF 2 MORE THAN HALF 3	0 1 2 3
D19.	OVERALL CONDITION OF UNDERDEVELOPED PROPERTY		EXCELLENT 1 GOOD 2 FAIR 3 POOR (ILLEGAL DUMPING) 4 MIXED 5	1 2 3 4 5
D20.	PARK OR PLAYGROUND		NO…(END QUESTIONNAIRE) 0 YES (PUBLIC) 1 YES (PRIVATE) 2	0 1 2
			SIDE A	SIDE B
D21.	CONDITION OF PLAYGROUND/ PARK		EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4	1 2 3 4
D22.	OCCUPANTS OF PLAYGROUND/ PARK (CHECK ALL THAT APPLY)		NONE 0 ADULTS ONLY 1 ADULTS WITH CHILDREN 2 TEEN GROUPS 3 UNACCOMPANIED CHILDREN 4	0 1 2 3 4

HEALTHY COMMUNITIES STUDY LUNCH OBSERVATION FORM
There is little to no public reporting burden of this collection of information as it is completed by research staff. 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.
SECTION A: REIMBURSABLE SCHOOL LUNCH FOODS AND BEVERAGES
	/ / mm dd yyyy
	Today’s Date			School ID
	: AM/PM Time			Liaison ID (Observer)
A1.	Get a copy of the month’s menu (if not able to obtain from school/district website prior to visit)				Already obtained Collected today Not available
THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BASED ON OBSERVATIONS MADE DURING 25 MINUTE OBSERVATION (not the menu obtained).
A2.	Total # of different entrées offered			# entrées
A3.	Salad bar as entrée			Yes No
A4.	Salad bar as side dish			Yes No
A5.	Number of fresh fruits and vegetables in salad bar			# fruits and vegetables No salad bar offered
A6.	Sandwich bar			Yes No
A7.	Other entrée bar			Y es Describe: ___________________ ___________________ No

A8.	Indicate how many different entrée options are offered for each category listed in the table below. Include reimbursable meal items only (not a la carte).
	Entrée item (part of reimbursable meal)	Offered?				Number of types offered
	Fast food-style
	Chicken burgers	N o  Yes
	Chicken nuggets (breaded and fried chicken pieces)	N o  Yes
	Hamburgers	N o  Yes
	Entrée item (part of reimbursable meal)	Offered?				Number of types offered
	Hot dogs/corn dogs	N o  Yes
	Nachos (with meat and/or cheese)	N o  Yes
	Pizza	N o  Yes
	Sandwiches (not burgers)	N o  Yes
	Wraps	N o  Yes
	Salads (meal/entrée sized)	N o  Yes
	Mexican-style
	Burritos	N o  Yes
	Quesadillas	N o  Yes
	Tacos	N o  Yes
	Other hot entrées
	Pasta with meat	N o  Yes
	Pasta with cheese	N o  Yes
	Soups, chilis, stews	N o  Yes
	Meat and potato	N o  Yes
	Meat and rice, Asian-style	N o  Yes
	Other 1: ______________________________	N o  Yes
	Other 2: ______________________________	No  Yes
	Other 3: ______________________________	N o  Yes
	Other 4: ______________________________	N o  Yes
A9.	Indicate whether the following beverages are offered as part of a reimbursable meal at no extra charge:
	Milk - white, whole or 2%	Yes  No
	Milk - flavored, whole or 2%	Yes  No
	Milk - white, 1% or nonfat	Yes  No
	Milk - flavored, 1% or nonfat	Yes  No
	Juice (100%) + water, no added sweeteners	Yes  No
	Juice, sweetened	Yes  No
	Sports drinks	Yes  No
	Soda, regular	Yes  No
	Other sweetened beverage (any beverage with added caloric sweetener not already listed above)	Yes  No
	Diet beverage	Yes  No
	Water, bottled, unsweetened	Yes  No
	Other beverage 1: _______________________	Yes  No
	Other beverage 2: _______________________	Yes  No
A10.	Please indicate the number of meal options that include the following:
		# meal options
	Grain product (100% whole wheat bread, pasta or tortillas, brown rice, corn tortillas)
	Grain product, not 100% whole grain
	Fruit, fresh
	Fruit, frozen, canned or dried
	Vegetable, French Fries
	Vegetable, other, fried
		# meal options
	Vegetable, fresh
	Vegetable, processed, i.e. canned, frozen
	Salad, side (tossed, raw vegetables)
A11.	Please indicate which desserts and snack items are offered as part of a reimbursable meal at no extra charge:
	Cake	Yes  No
	Cookie	Yes  No
	Other pastries	Yes  No
	Candy	Yes  No
	Ice Cream	Yes  No
	Low-fat frozen desserts	Yes  No
	Other frozen desserts	Yes  No
	Chips (corn, potato, puffed cheese, tortilla)	Yes  No
	Chips (lower/reduced fat, baked)	Yes  No
	Other 1: _______________________________	Yes  No
	Other 2: _______________________________	Yes  No
SECTION B: SCHOOL DINING FACILITIES
B1.	Presence of indoor dining areas Please  only one.			N Skip to B4 one (no indoor dining areas provided) Informal (students can eat inside but no seating AND tables provided for this purpose) Formal (indoor eating with seating AND tables provided for this purpose)
B2.	Size of indoor dining area Please  all that apply.			Big enough Too small Not enough seating Too crowded Not too crowded
B3.	Indoor dining décor / ambiance: Please  only one.			Exceptional Pleasant (clean, cheerful, inviting) Acceptable (clean, well-kept, but sparse) Some areas of concern (dirty, dingy, needs repairs, etc.)
B4.	Presence of outdoor dining areas Please  only one.			N Skip to B7 one (no outdoor dining areas provided) Informal (students can eat outside but no seating AND tables provided for this purpose) Formal (outdoor eating with seating AND tables provided for this purpose)
B5.	Size of outdoor dining area Please  all that apply.			Big enough Too small Not enough seating Too crowded Not too crowded
B6.	Outdoor dining décor / ambiance: Please  only one.			Exceptional Pleasant (clean, cheerful, inviting) Acceptable (clean, well-kept, but sparse) Some areas of concern (dirty, dingy, needs repairs, etc.)
B7.	In their interactions with students, most staff were: Please  only one.			Engaging (smiling, interactive, encouraging) Pleasant but not engaging Neutral (interact enough to process the students’ meals) Impolite, impatient, or negative with students Unable to observe
B8.	The longest meal service lines (during the time observed) consisted of approximately _____ students.			# of students
B9.	Meal service lines were observed over a span of ____ minutes.			minutes
B10.	Most students were served by ____:____ (not including stragglers)			: AM/PM Unable to observe
B11.	Time when meal period started			: AM/PM
	ended			: AM/PM

B12.

In what forms is unsweetened water available free of charge in the dining or serving areas? Please  all that apply.

Water fountain Pitcher Bottles Dispenser Other None

B13.

Other observations or clarifications:

SECTION C: COMPETITIVE FOODS SOLD TO STUDENTS ON CAMPUS

C1.

Number of Competitive Food Venues Operating at any time during the school day:

Location

(Record a number in each box – write zero if none.)

Venue Type

Cafeteria

Hallway

Quad

Gym

Other

#

A la carte

_________

Vending machine

_________

School store

_________

Other 1: ______________

_________

Other 2: ______________

_________

Other 3: ______________

_________

C2.

Competitive Foods Sold During the School Day– Type and location

Please  all that apply.

Beverages

A la carte

Vending machine

School store

Other

Diet beverage









Juice (100%) + water, no added sweeteners (including 100% juice smoothies)









Juice, sweetened









Milk, white, whole or 2%









Milk flavored, whole or 2%









Milk White, 1% or nonfat









Milk flavored, 1% or nonfat









Soda, regular









Sports drinks









Other sweetened beverage (beverage w/ added caloric sweetener not listed above)









	Please  all that apply.
	Water, no added sweeteners					
			* Check this box if there appears to be an option with >50% whole grain.
	Baked Goods - Dessert	Whole grain option	A la carte	Vending machine	School store	Other
	Cake type (brownies, cupcakes, Twinkies)					
	Cake type (lower/reduced fat)					
	Cookies					
	Cookies (lower/reduced fat)					
	Muffins					
	Muffins (lower/reduced fat)					
	Pastries (donuts, pies, turnovers, toaster pastries)					
	Pastries (lower/reduced fat)					
	Cereals	Whole grain option	A la carte	Vending machine	School store	Other
	Cereal frosted or flavored					
	Cereal not frosted or flavored					
	Frozen desserts		A la carte	Vending machine	School store	Other
	Frozen, non-dairy (fruit bars, Jell-O pops, Popsicles)					
	Ice cream (bars, Fudgesicles, scoops, cups, sundaes, sandwiches)					
	Low-fat frozen desserts (frozen yogurt, ice milk, sherbet)					
	Milkshake					
	Fruit		A la carte	Vending machine	School store	Other
	Canned or cooked fruit					
	Dried fruit					
	Fresh fruit					
	Meat/Meat Alternative Entrées/Mixed Dishes	Whole grain option	A la carte	Vending machine	School store	Other
	Burritos					
	Chicken burger					
	Chicken pieces/nuggets (breaded)					
	Hamburger/cheeseburger					
	Hot dog/corn dog					
			Please  all that apply.
			A la carte	Vending machine	School store	Other
	Meat with rice (Chinese-/Asian-style)					
	Nacho chips with salsa					
	Nacho chips (with meat, beans or cheese)					
	Pasta (spaghetti, macaroni and cheese, pasta salad)					
	Pizza					
	Ramen-type soup/cup of noodles					
	Salad, meal-sized (chef's, grilled chicken)					
	Sandwiches, cold					
	Sandwiches, grilled/hot					
	Soup/chilis/stews with beans or meat (chicken, clam chowder, minestrone)					
	Tacos					
	Wraps					
	Vegetables		A la carte	Vending machine	School store	Other
	Fried potatoes (including pre-fried, oven baked, French fries, tater tots, potato skins)					
	Salad - side (tossed, raw vegetables)					
	Vegetables (not fried)					
	Snacks	Whole grain option	A la carte	Vending machine	School store	Other
	Candy/chocolate					
	Chips (corn, potato, puffed cheese, tortilla)					
	Chips (lower/reduced fat/baked)					
	Corn nuts					
	Crackers,(regular)					
	Crackers (lower/reduced fat)/pretzels					
	Fruit roll-up or fruit snacks with added sugar					
	Granola bars/cereal bars/energy bars/other snack bars					
	Meat snacks (jerky, salami, pork rinds)					
	Nuts and seeds (almonds, sunflower seeds)					

			Please  all that apply.
			A la carte	Vending machine	School store	Other
	Popcorn, air-popped or low-fat					
	Popcorn, buttered or flavored					
	Trail mix, without candy					
	Trail mix with candy					
	Yogurt, flavored					
	Yogurt, plain					
	Other foods (specify):	Whole grain option	A la carte	Vending machine	School store	Other
	______________________					
	______________________					
	______________________					
	______________________					
	______________________					
	______________________					
	______________________					
	______________________					

LUNCH OBSERVATION FORM

Sources and References

1. UC Berkeley Atkins Center for Weight and Health (CWH) school nutrition environment observation forms (not published)

2. U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS). School Nutrition Dietary Assessment (SNDA) Study III, Pre-Visit Questionnaire and Menu Survey – Reimbursable Meals Form. Retrieved on November 14, 2010 from http://www.fns.usda.gov/oane/MENU/Published/CNP/cnp.htm

HEALTHY COMMUNITIES STUDY THE SCHOOL PHYSICAL ACTIVITY RESOURCE ASSESSMENT (SCHOOL PARA)

There is little to no public reporting burden of this collection of information as it is completed by research staff. 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.

PLEASE COMPLETE THE FOLLOWING FORM FOR THE FOUR SCHOOLS SELECTED FOR OBSERVATIONS IN THE COMMUNITY DURING THE LIAISON’S INITIAL VISIT.

B1.

Start Time (Military time)

End Time (Military time)

B2.

Approximate size (size of entire school property)

small (1/2 square block) medium (>1/2 square block up to 1 square block) large (>1 square block)

B3.

Capacity (posted fire capacity for indoor facilities)

B4.

Cost

Free Pay at the door Pay for only certain programs Other _______________________

B5.

Hours of Operation (record in military time)

a) open b) close

B6.

Signage – Hours

Yes No

B7.

Signage – Rules

Yes No

FOR QUESTIONS BELOW, PLEASE REFER TO PROTOCOL AND OPERATIONAL DEFINITIONS WITH PICTURES. Please note for B13: Play equipment - If it is ‘typical’ equipment such as a slide, swings, horizontal bar; no description is necessary. When the equipment is unusual, please describe and use the Comments space as necessary.

Rating

Rating

Feature

Not present

Poor

Mediocre

Good

Amenity

Not present

Poor

Mediocre

Good

B8.

Baseball field









B21.

Access points









B9.

Basketball courts









B22.

Bathrooms









B10.

Soccer field









B23.

Benches









B11.

Bike rack









B24.

Drinking fountain









B12.

Exercise stations









B25.

Fountains









B13.

Play equipment









B26.

Landscaping efforts









B14.

Pool >3 ft deep









B27.

Lighting









B15.

Sandbox









B28.

Picnic tables shaded









B16.

Sidewalk









B29.

Picnic tables no-shade









B17.

Tennis courts









B30.

Shelters









B18.

Trails – running/ biking









B31.

Shower/Locker room









B19.

Volleyball courts









B32.

Trash containers









B20.

Wading pool <3ft









Incivilities

Incivilities

B33.

Auditory annoyance









B39.

Graffiti/tagging









B34.

Broken glass









B40.

Litter









B35.

Dog refuse









B41.

No grass









B36.

Dogs unattended









B42.

Overgrown grass









B37.

Evidence of alcohol use









B43.

Sex paraphernalia









B38.

Evidence of substance use









B44.

Vandalism









Comments: __________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

HEALTHY COMMUNITIES STUDY T There is little to no public reporting burden of this collection of information as it is completed by research staff. 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. HE PHYSICAL ACTIVITY RESOURCE ASSESSMENT (PARA)

.

PLEASE COMPLETE THE FOLLOWING FORM FOR SCHOOLS AND PHYSICAL ACTIVITY RESOURCES IN THE COMMUNITY

1.

/ / mm dd yyyy Today’s Date

2.

Liaison ID (Observer)

3.

School ID

4.

Start Time (Military time)

End Time (Military time)

5.

Type of resource

Fitness club Park Sport facility Trail Community Center Church School Combination: _________________

6.

Approximate size (size of entire resource)

small (1/2 square block) medium (>1/2 square block up to 1 square block) large (>1 square block)

7.

Capacity (posted fire capacity for indoor facilities)

8.

Cost

Free Pay at the door Pay for only certain programs Other _______________________

9.

Hours of Operation (record in military time)

a) open b) close

10.

Signage – Hours

Yes No

11.

Signage – Rules

Yes No

FOR QUESTIONS BELOW, PLEASE REFER TO PROTOCOL AND OPERATIONAL DEFINITIONS WITH PICTURES. Please note for 13: Play equipment - If it is ‘typical’ equipment such as a slide, swings, horizontal bar; no description is necessary. When the equipment is unusual, please describe and use the Comments space as necessary.

Rating

Rating

Feature

Not present

Poor

Mediocre

Good

Amenity

Not present

Poor

Mediocre

Good

8.

Baseball field









21.

Access points









9.

Basketball courts









22.

Bathrooms









10.

Soccer field









23.

Benches









11.

Bike rack









24.

Drinking fountain









12.

Exercise stations









25.

Fountains









13.

Play equipment









26.

Landscaping efforts









14.

Pool >3 ft deep









27.

Lighting









15.

Sandbox









28.

Picnic tables shaded









16.

Sidewalk









29.

Picnic tables no-shade









17.

Tennis courts









30.

Shelters









18.

Trails – running/ biking









31.

Shower/Locker room









19.

Volleyball courts









32.

Trash containers









20.

Wading pool <3ft









Incivilities

Incivilities

33.

Auditory annoyance









39.

Graffiti/tagging









34.

Broken glass









40.

Litter









35.

Dog refuse









41.

No grass









36.

Dogs unattended









42.

Overgrown grass









37.

Evidence of alcohol use









43.

Sex paraphernalia









38.

Evidence of substance use









44.

Vandalism









Comments: __________________________________________________________________ ____________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________

PHYSICAL ACTIVITY OBSERVATIONS

Sources and References

THE SCHOOL PHYSICAL ACTIVITY RESOURCE ASSESSMENT (SCHOOL PARA)

1. Lee RE, Booth KM, Reese-Smith JY, Regan G, Howard HH. The Physical Activity Resource Assessment (PARA) instrument: evaluating features, amenities, and incivilities of physical activity resources in urban neighborhoods. Int J Behav Nutr Phys Act. 14 September 2005; 2:13.

THE PHYSICAL ACTIVITY RESOURCE ASSESSMENT (PARA)

1. Lee RE, Booth KM, Reese-Smith JY, Regan G, Howard HH. The Physical Activity Resource Assessment (PARA) instrument: evaluating features, amenities, and incivilities of physical activity resources in urban neighborhoods. Int J Behav Nutr Phys Act. 14 September 2005; 2:13.

HEALTHY COMMUNITIES STUDY

GROUND-TRUTHING OF

GEOGRAPHIC INFORMATION SYSTEM (GIS) MAPPING

Once GIS data is obtained, it will be formatted into a form containing commercial venues and resources to be verified so that the Battelle community liaison (during his or her second visit to the community) or community documenter may complete “ground-truthing” of GIS data.

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