Impact Evaluation Instruments - Households

Eval of SNAP Nutrition Edu Practices Study - Wave II

Appendix A. Impact Evaluation Data Collecting Instrument UKCES 3.16.11

Impact Evaluation Instruments - Households

OMB: 0584-0554

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Instruments for the University of Kentucky Cooperative Extension Service Impact Evaluation

OMB No. 0584-0554

Expiration date: XX/XX/20XX

See OMB statement on inside cover

Pre-Survey: Intervention and Control Groups

Thank you for taking part in this important study!

Please fill out and return the survey in the enclosed envelope within the next week.

If you have any questions about the What Does Your Child Eat? study, please send an e‑mail to [email protected] or call toll-free at 1-866-800-9176.

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: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0554). Do not return the completed form to this address.

If you have questions regarding your rights as a research participant, you may contact RTI’s Office of Research Protection toll-free at 866-214-2043.

This survey asks about what your child eats. This study is being sponsored by the U.S. Department of Agriculture’s Food and Nutrition Service and conducted by RTI International, a nonprofit research organization. The survey will take about 15 minutes to fill out. You will receive $10 for filling out this survey and $15 for filling out a second survey that we will mail to you in about 5 months.

All of your answers to the survey will be kept private. We will not share your answers with anyone, except as otherwise required by law. You may skip any questions you do not want to answer. If you have any questions, please call Matthew Bensen at RTI at
1-866-800-9176.

Questions on Whether Certain Foods Are Available at Home

Were any of these foods in your home during the past week? Include fresh, frozen, canned, and dried foods. (Circle Yes or No for each food.)

a. Bananas	Yes	No
b. Apples	Yes	No
c. Grapes	Yes	No
d. Raisins	Yes	No
e. Berries	Yes	No
f. Celery	Yes	No
g. Carrots	Yes	No
h. Broccoli	Yes	No
i. Zucchini	Yes	No
j. Potato chips, tortilla chips, corn chips, or other chips	Yes	No
k. Regular soft drinks or sodas	Yes	No

Questions on the Fruits and Vegetables Your Child Eats

For the next questions, think about what your child ate during the past week, or the past 7 days. Do NOT include school, before/after school care, or day care.

How many days during the past week did your child eat more than one kind of fruit each day? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do NOT include fruit juice. (Circle one.)^¹

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

How many days during the past week did your child eat more than one kind of vegetable each day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Think about what your child ate during the past week. About how many cups of vegetables did your child eat on a typical day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? (Circle all that apply.)

1. No, did not eat breakfast, lunch, or snacks provided by school, before or after school care program, or day care

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

Is your child willing to try a new kind of fruit? Do NOT include fruit juice. (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child fruit for a snack? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child fruit at dinner? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Is your child willing to try a new kind of vegetable? (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child a vegetable for a snack? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child a vegetable at dinner? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Shopping and Eating Habits

How strongly do you agree or disagree with each of these statements? (Circle one for each statement.)

a. It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree
b. There is a large selection of fresh fruits or vegetables available where I live.	Strongly agree	Agree	Disagree	Strongly disagree
c. I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree
d. I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree
e. I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree

During the past month, how often did your child ask you to buy a certain type of fruit? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

During the past month, how often did your child ask you to buy a certain type of vegetable? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

How many days during the past week did your child help you make or cook a meal? For example, did your child wash fruits or vegetables? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you and your child sit down to eat dinner as a family? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child eat dinner with the TV on? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child help select the food your family eats at home? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child ask to have fruits or vegetables to eat? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions about You and Your Household

Does anyone in your household currently get Food Stamps or Supplemental Nutrition Assistance Program (SNAP) benefits? (Circle one.)

1. No

2. Yes

Does anyone in your household currently get Women, Infants, and Children (WIC) program benefits? (Circle one.)

1. No

2. Yes

How many people under 18 years of age live in your household?

____

Including yourself, how many people 18 years of age or older live in your household?

____

What is your age? (Circle one.)

1. 18 to 24

2. 25 to 34

3. 35 to 44

4. 45 to 54

5. 55 to 64

6. 65 to 74

7. Over 74

What is your gender? (Circle one.)

1. Male

2. Female

Please answer the next two questions about your ethnicity and race.

27. What is your ethnicity? (Circle one.)

1. Hispanic or Latino

2. Not Hispanic or Latino

What is your race? (Circle one or more.)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or other Pacific Islander

5. White

In what month was the child who is participating in the “What Does Your Child Eat” study born? (Circle one.)

1. January

2. February

3. March

4. April

5. May

6. June

7. July

8. August

9. September

10. October

11. November

12. December

In what year was the child who is participating in the “What Does Your Child Eat” study born? (Enter year; for example, 2004.)

_________

Thank you for completing our survey.
Please return the survey in the enclosed envelope.

If you have misplaced the envelope, call 1-866-800-9176
for a replacement or mail the survey to
RTI INTERNATIONAL
ATTN: Data Capture (0212343.001.008.002)
PO Box 12194
Research Triangle Park, NC 27709-9779

OMB No. 0584-0554

Expiration date: XX/XX/20XX

What Does Your Child Eat?
Telephone Questionnaire for Nonrespondents to Mail Survey

(Pre-survey, Intervention and Control Groups)

Instrument for UKCES Impact Evaluation

To begin the survey, I’m going to read a list of foods. For each food, please tell me if it was in your home during the past week. Please include fresh, frozen, canned, and dried foods. Answer yes or no for each food. The first food is…

a. Bananas	YES	NO	DK	RF
b. Apples	YES	NO	DK	RF
c. Grapes	YES	NO	DK	RF
d. Raisins	YES	NO	DK	RF
e. Berries	YES	NO	DK	RF
f. Celery	YES	NO	DK	RF
g. Carrots	YES	NO	DK	RF
h. Broccoli	YES	NO	DK	RF
i. Zucchini	YES	NO	DK	RF
j. Potato chips, tortilla chips, corn chips, or other chips	YES	NO	DK	RF
k. Regular soft drinks or sodas	YES	NO	DK	RF

For the next questions, think about what your child ate during the past week, or the past 7 days. Do not include school, before, or after school care, or day care.

How many days during the past week did your child eat more than one kind of fruit each day? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do not include fruit juice. Would you say your child had…? SELECT ONE.

1. No fruit

2. ½ cup

3. 1 cup

4. 1 ½ cups

5. 2 cups

6. 2 ½ cups, or

7. 3 cups or more

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child eat more than one kind of vegetable each day? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Think about what your child ate during the past week. About how many cups of vegetables did your child eat on a typical day? Do not include white potatoes, French fries, or vegetable juice. Would you say your child had…? SELECT ONE.

1. No vegetables

2. ½ cup

3. 1 cup

4. 1 ½ cups

5. 2 cups

6. 2 ½ cups, or

7. 3 cups or more

-4. DON’T KNOW

-7. REFUSAL

During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? You can select all the answers that apply. Would you say…? SELECT ALL THAT APPLY.

1. My child did not eat any meals or snacks provided by the school or other program

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

-4. DON’T KNOW

-7. REFUSAL

Is your child willing to try a new kind of fruit? Do not include fruit juice. Would you say…? SELECT ONE.

1. No

2. Maybe, or

3. Yes

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child fruit for a snack? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child fruit at dinner? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Is your child willing to try a new kind of vegetable? Would you say…? SELECT ONE.

1. No

2. Maybe, or

3. Yes

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child a vegetable for a snack? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child a vegetable at dinner? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Now, I’m going to read you several statements. For each statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree with the statement.

The first/next statement is… How strongly do you agree or disagree with this statement? Would you say strongly agree, agree, disagree, or strongly disagree? REPEAT AFTER EVERY 3 STATEMENTS. SELECT ONE FOR EACH STATEMENT.

a. It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
b. There is a large selection of fresh fruits or vegetables available where I live.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
c. I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
d. I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
e. I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF

During the past month, how often did your child ask you to buy a certain type of fruit? Would you say…? SELECT ONE.

1. Never

2. Seldom

3. Sometimes

4. Often, or

5. Always

-4. DON’T KNOW

-7. REFUSAL

During the past month, how often did your child ask you to buy a certain type of vegetable? Would you say…? SELECT ONE.

1. Never

2. Seldom

3. Sometimes

4. Often, or

5. Always

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child help you make or cook a meal? For example, did your child wash fruits or vegetables? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you and your child sit down to eat dinner as a family? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child eat dinner with the TV on? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child help select the food your family eats at home? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child ask to have fruits or vegetables to eat? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Does anyone in your household currently get Food Stamps or Supplemental Nutrition Assistance Program, SNAP, benefits? SELECT ONE.

1. NO

2. YES

-4. DON’T KNOW

-7. REFUSAL

Does anyone in your household currently get Women, Infants, and Children, WIC, program benefits? SELECT ONE.

1. NO

2. YES

-4. DON’T KNOW

-7. REFUSAL

How many people under 18 years of age live in your household?

____

-4. DON’T KNOW

-7. REFUSAL

Including yourself, how many people 18 years of age or older live in your household?

____

-4. DON’T KNOW

-7. REFUSAL

What is your age? SELECT ONE.

1. 18 to 24

2. 25 to 34

3. 35 to 44

4. 45 to 54

5. 55 to 64

6. 65 to 74, or

7. Over 74

-4. DON’T KNOW

-7. REFUSAL

What is your gender? SELECT ONE.

1. MALE

2. FEMALE

-4. DON’T KNOW

-7. REFUSAL

Please answer the next two questions about your ethnicity and race.

What is your ethnicity? (Circle one.)

1. Hispanic or Latino

2. Not Hispanic or Latino

-4. DON’T KNOW

-7. REFUSAL

What is your race? You can select one or more answers. SELECT ONE OR MORE.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or other Pacific Islander

5. White

-4. DON’T KNOW

-7. REFUSAL

In what month was the child who is participating in the “What Does Your Child Eat” study born? SELECT ONE.

1. January

2. February

3. March

4. April

5. May

6. June

7. July

8. August

9. September

10. October

11. November

12. December

-4. DON’T KNOW

-7. REFUSAL

In what year was the child who is participating in the “What Does Your Child Eat” study born?

____

-4. DON’T KNOW

-7. REFUSAL

31. That is all the questions I have. Thank you for completing our survey. Before saying goodbye, I’d like to confirm that I have your correct name and address for sending your cash incentive in appreciation for completing this survey. I have [RESPONDENT NAME] spelled _____________________. Is this correct?

1. YES

2. CORRECT NAME [PROGRAMMER – SET UP TO ENTER CORRECTIONS]

-7. REFUSAL

32. For your street address, I have [RESPONDENT STREET ADDRESS] Is this correct (IF NO APT NUMBER: or is there an apartment or unit number)?

1. YES

2. NO [PROGRAMMER – SET UP TO ENTER CORRECT ADDRESS]

-7. REFUSAL

33. For your city, state, and zip code, I have [RESPONDENT CITY, STATE, and ZIP CODE] Is this correct?

1. YES

2. CORRECT CITY

3. CORRECT STATE

4. CORRECT ZIPCODE [PROGRAMMER – SET UP TO ALLOW FOR GENERATION OF ADDRESS LABELS FOR INCENTIVE LETTERS]

-7. REFUSAL

Thank you again. Have a nice (day/evening).

OMB No. 0584-0554

Expiration date: XX/XX/20XX

See OMB statement on inside cover

Post-Survey: Intervention Group

Thank you for taking part in this important study!

Please fill out and return the survey in the enclosed envelope within the next week.

If you have any questions about the What Does Your Child Eat? study, please send an e‑mail to [email protected] or call toll-free at 1-866-800-9176.

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.

If you have questions regarding your rights as a research participant, you may contact RTI’s Office of Research Protection toll-free at 866-214-2043.

This survey asks about what your child eats. You may recall that we asked some of the same questions in the last survey. This study is being sponsored by the U.S. Department of Agriculture’s Food and Nutrition Service and conducted by RTI International, a nonprofit research organization. The survey will take about 15 minutes to complete. You will receive $15 for completing this survey.

Questions on Whether Certain Foods Are Available at Home

Were any of these foods in your home during the past week? Include fresh, frozen, canned, and dried foods. (Circle Yes or No for each food.)

a. Bananas	Yes	No
b. Apples	Yes	No
c. Grapes	Yes	No
d. Raisins	Yes	No
e. Berries	Yes	No
f. Celery	Yes	No
g. Carrots	Yes	No
h. Broccoli	Yes	No
i. Zucchini	Yes	No
j. Potato chips, tortilla chips, corn chips, or other chips	Yes	No
k. Regular soft drinks or sodas	Yes	No

Questions on the Fruits and Vegetables Your Child Eats

For the next questions, think about what your child ate during the past week, or the past 7 days. Do NOT include school, before/after school care, or day care.

How many days during the past week did your child eat more than one kind of fruit each day? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do NOT include fruit juice. (Circle one.)^²

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

How many days during the past week did your child eat more than one kind of vegetable each day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? (Circle all that apply.)

1. No, did not eat breakfast, lunch, or snacks provided by school, before or after school care program, or day care

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

Is your child willing to try a new kind of fruit? Do NOT include fruit juice. (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child fruit for a snack? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child fruit at dinner? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Is your child willing to try a new kind of vegetable? (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child a vegetable for a snack? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child a vegetable at dinner? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Shopping and Eating Habits

How strongly do you agree or disagree with each of these statements? (Circle one for each statement.)

a. It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree
b. There is a large selection of fresh fruits or vegetables available where I live.	Strongly agree	Agree	Disagree	Strongly disagree
c. I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree
d. I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree
e. I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree

During the past month, how often did your child ask you to buy a certain type of fruit? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

During the past month, how often did your child ask you to buy a certain type of vegetable? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

How many days during the past week did your child help you make or cook a meal? For example, did your child wash fruits or vegetables? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you and your child sit down to eat dinner as a family? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child eat dinner with the TV on? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child help select the food your family eats at home? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child ask to have fruits or vegetables to eat? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Nutrition Education Materials Your Child Got at School

Did the child participating in the “What Does Your Child Eat Study” change schools during the school year?

1. No [Go to Question 23]

2. Yes

What is the name of your child’s new school and the county in which it is located?

School name:

County:

Your child’s teacher sent home newsletters with tips on healthy eating and recipes. How many newsletters did you or someone else in your household read? (Circle one.)

1. Did not get newsletters [Go to Question 28]

2. None

3. 1 to 2

4. 3 to 4

5. 5 to 6

6. 7 to 8

How many of the recipes in the newsletters did you or someone else in your household use to make a snack or meal for your child? (Circle one.)

1. None

2. 1 to 2

3. 3 to 4

4. 5 to 6

5. 7 to 8

How easy was it to understand the newsletters? (Circle one.)

1. Not at all easy

2. Not very easy

3. Somewhat easy

4. Easy

5. Very easy

How strongly do you agree or disagree with this statement? “I used the information from the newsletter(s) to help my child eat healthier foods.” (Circle one.)

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

Please share any comments about the newsletters.

Did your child tell you that his/her class read any of these books at school? (Circle Yes or No for each book.)

a. “ABC's of Fruits and Vegetables and Beyond”	Yes	No
b. “Blueberries for Sal”	Yes	No
c. “Sesame Street: Happy Healthy Monsters”	Yes	No
d. “Bread and Jam for Frances”	Yes	No
e. “Tops and Bottoms”	Yes	No

Did your child tell you that he/she had a food tasting at school? (Circle one.)

1. No

2. Yes

Thank you for completing our survey.
Please return the survey in the enclosed envelope.

If you have misplaced the envelope, call 1-866-800-9176
for a replacement or mail the survey to

RTI INTERNATIONAL

ATTN: Data Capture (0212343.001.008.002)

PO Box 12194

Research Triangle Park, NC 27709-9779

OMB No. 0584-0554

Expiration date: XX/XX/20XX

See OMB statement on inside cover

Post-Survey: Control Group

Thank you for taking part in this important study!

Please fill out and return the survey in the enclosed envelope within the next week.

If you have any questions about the What Does Your Child Eat? study, please send an e‑mail to [email protected] or call toll-free at 1-866-800-9176.

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.

If you have questions regarding your rights as a research participant, you may contact RTI’s Office of Research Protection toll-free at 866-214-2043.

Questions on Whether Certain Foods Are Available at Home

Were any of these foods in your home during the past week? Include fresh, frozen, canned, and dried foods. (Circle Yes or No for each food.)

a. Bananas	Yes	No
b. Apples	Yes	No
c. Grapes	Yes	No
d. Raisins	Yes	No
e. Berries	Yes	No
f. Celery	Yes	No
g. Carrots	Yes	No
h. Broccoli	Yes	No
i. Zucchini	Yes	No
j. Potato chips, tortilla chips, corn chips, or other chips	Yes	No
k. Regular soft drinks or sodas	Yes	No

Questions on the Fruits and Vegetables Your Child Eats

For the next questions, think about what your child ate during the past week, or the past 7 days. Do NOT include school, before/after school care, or day care.

How many days during the past week did your child eat more than one kind of fruit each day? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do NOT include fruit juice. (Circle one.)^³

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

How many days during the past week did your child eat more than one kind of vegetable each day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

1. None
2. ½ cup
3. 1 cup
4. 1 ½ cups
5. 2 cups	None	1 cup	2 cups	3 cups
6. 2 ½ cups
7. 3 cups or more

During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? (Circle all that apply.)

1. No, did not eat breakfast, lunch, or snacks provided by school, before or after school care program, or day care

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

Is your child willing to try a new kind of fruit? Do NOT include fruit juice. (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child fruit for a snack? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child fruit at dinner? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Is your child willing to try a new kind of vegetable? (Circle one.)

1. No

2. Maybe

3. Yes

How many days during the past week did you give your child a vegetable for a snack? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you give your child a vegetable at dinner? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Shopping and Eating Habits

How strongly do you agree or disagree with each of these statements? (Circle one for each statement.)

a. It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree
b. There is a large selection of fresh fruits or vegetables available where I live.	Strongly agree	Agree	Disagree	Strongly disagree
c. I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree
d. I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree
e. I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree

During the past month, how often did your child ask you to buy a certain type of fruit? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

During the past month, how often did your child ask you to buy a certain type of vegetable? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

How many days during the past week did your child help you make or cook a meal? For example, did your child wash fruits or vegetables? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did you and your child sit down to eat dinner as a family? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child eat dinner with the TV on? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child help select the food your family eats at home? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

How many days during the past week did your child ask to have fruits or vegetables to eat? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Did the child participating in the “What Does Your Child Eat Study” change schools during the school year?

1. No

2. Yes

What is the name of your child’s new school and the county in which it is located?

School name:

County:

Thank you for completing our survey.
Please return the survey in the enclosed envelope.

If you have misplaced the envelope, call 1-866-800-9176
for a replacement or mail the survey to

RTI INTERNATIONAL

ATTN: Data Capture (0212343.001.008.002)

PO Box 12194

Research Triangle Park, NC 27709-9779

OMB No. 0584-0554

Expiration date: XX/XX/20XX

What Does Your Child Eat?
Telephone Questionnaire for Nonrespondents to Mail Survey

(Post-survey, Intervention and Control Groups)

Instrument for UKCES Impact Evaluation

To begin the survey, I’m going to read a list of foods. For each food, please tell me if it was in your home during the past week. Please include fresh, frozen, canned, and dried foods. Answer yes or no for each food. The first food is…

a. Bananas	YES	NO	DK	RF
b. Apples	YES	NO	DK	RF
c. Grapes	YES	NO	DK	RF
d. Raisins	YES	NO	DK	RF
e. Berries	YES	NO	DK	RF
f. Celery	YES	NO	DK	RF
g. Carrots	YES	NO	DK	RF
h. Broccoli	YES	NO	DK	RF
i. Zucchini	YES	NO	DK	RF
j. Potato chips, tortilla chips, corn chips, or other chips	YES	NO	DK	RF
k. Regular soft drinks or sodas	YES	NO	DK	RF

For the next questions, think about what your child ate during the past week, or the past 7 days. Do not include school, before, or after school care, or day care.

How many days during the past week did your child eat more than one kind of fruit each day? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do not include fruit juice. Would you say your child had…? SELECT ONE.

1. No fruit

2. ½ cup

3. 1 cup

4. 1 ½ cups

5. 2 cups

6. 2 ½ cups, or

7. 3 cups or more

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child eat more than one kind of vegetable each day? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Think about what your child ate during the past week. About how many cups of vegetables did your child eat on a typical day? Do not include white potatoes, French fries, or vegetable juice. Would you say your child had…? SELECT ONE.

1. No vegetables

2. ½ cup

3. 1 cup

4. 1 ½ cups

5. 2 cups

6. 2 ½ cups, or

7. 3 cups or more

-4. DON’T KNOW

-7. REFUSAL

During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? You can select all the answers that apply. Would you say…? SELECT ALL THAT APPLY.

1. My child did not eat any meals or snacks provided by the school or other program

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

-4. DON’T KNOW

-7. REFUSAL

Is your child willing to try a new kind of fruit? Do not include fruit juice. Would you say…? SELECT ONE.

1. No

2. Maybe, or

3. Yes

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child fruit for a snack? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child fruit at dinner? Do not include fruit juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Is your child willing to try a new kind of vegetable? Would you say…? SELECT ONE.

1. No

2. Maybe, or

3. Yes

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child a vegetable for a snack? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you give your child a vegetable at dinner? Do not include white potatoes, French fries, or vegetable juice. Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Now, I’m going to read you several statements. For each statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree with the statement.

a. It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
b. There is a large selection of fresh fruits or vegetables available where I live.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
c. I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
d. I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF
e. I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree	DK	RF

During the past month, how often did your child ask you to buy a certain type of fruit? Would you say…? SELECT ONE.

1. Never

2. Seldom

3. Sometimes

4. Often, or

5. Always

-4. DON’T KNOW

-7. REFUSAL

During the past month, how often did your child ask you to buy a certain type of vegetable? Would you say…? SELECT ONE.

1. Never

2. Seldom

3. Sometimes

4. Often, or

5. Always

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child help you make or cook a meal? For example, did your child wash fruits or vegetables? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did you and your child sit down to eat dinner as a family? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child eat dinner with the TV on? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child help select the food your family eats at home? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

How many days during the past week did your child ask to have fruits or vegetables to eat? Would you say…? SELECT ONE.

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days, or

5. Every day

-4. DON’T KNOW

-7. REFUSAL

Did the child participating in the “What Does Your Child Eat Study” change schools during the school year? SELECT ONE.

1. NO [Go to Question 23]

2. YES

-4. DON’T KNOW [Go to Question 23]

-7. REFUSAL [Go to Question 23]

22a. What is the name of your child’s new school?

School name:

22b. What is the name of the county in which it is located?

County:

[IF ADMINISTRATION IS POST-SURVEY, CONTROL GROUP ONLY, GO TO Q30.]

The last set of questions asks about materials your child got at school and may have brought home.

First, your child’s teacher sent home newsletters with tips on healthy eating and recipes. How many newsletters did you or someone else in your household read? Would you say…? SELECT ONE.

1. DID NOT GET NEWSLETTERS [Go to Question 28]

2. None

3. 1 to 2

4. 3 to 4

5. 5 to 6, or

6. 7 to 8

-4. DON’T KNOW [Go to Question 28]

-7. REFUSAL [Go to Question 28]

How many of the recipes in the newsletters did you or someone else in your household use to make a snack or meal for your child? Would you say…? SELECT ONE.

1. None

2. 1 to 2

3. 3 to 4

4. 5 to 6, or

5. 7 to 8

-4. DON’T KNOW

-7. REFUSAL

How easy was it to understand the newsletters? Would you say…? SELECT ONE.

1. Not at all easy

2. Not very easy

3. Somewhat easy

4. Easy, or

5. Very easy

-4. DON’T KNOW

-7. REFUSAL

How strongly do you agree or disagree with this statement? “I used the information from the newsletters to help my child eat healthier foods.” Would you say…? SELECT ONE.

1. Strongly agree

2. Agree

3. Disagree, or

4. Strongly disagree

-4. DON’T KNOW

-7. REFUSAL

Please share any comments about the newsletters.

Now I’m going to read you the titles of several books. For each book, please tell me whether your child told you that his/her class read the book at school. The first book is… SELECT ONE FOR EACH STATEMENT.

a. “ABC's of Fruits and Vegetables and Beyond”	YES	NO	DK	RF
b. “Blueberries for Sal”	YES	NO	DK	RF
c. “Sesame Street: Happy Healthy Monsters”	YES	NO	DK	RF
d. “Bread and Jam for Frances”	YES	NO	DK	RF
e. “Tops and Bottoms”	YES	NO	DK	RF

Did your child tell you that he/she had a food tasting at school? SELECT ONE.

1. NO

2. YES

-4. DON’T KNOW

-7. REFUSAL

30. That is all the questions I have. Thank you for completing our survey. Before saying goodbye, I’d like to confirm that I have your correct name and address for sending your cash incentive in appreciation for completing this survey. I have [RESPONDENT NAME] spelled _____________________. Is this correct?

1. YES

2. CORRECT NAME [PROGRAMMER – SET UP TO ENTER CORRECTIONS]

-7. REFUSAL

31. For your street address, I have [RESPONDENT STREET ADDRESS] Is this correct (IF NO APT NUMBER: or is there an apartment or unit number)?

1. YES

2. NO [PROGRAMMER – SET UP TO ENTER CORRECT ADDRESS]

-7. REFUSAL

32. For your city, state, and zip code, I have [RESPONDENT CITY, STATE, and ZIP CODE] Is this correct?

1. YES

2. CORRECT CITY

3. CORRECT STATE

4. CORRECT ZIPCODE [PROGRAMMER – SET UP TO ALLOW FOR GENERATION OF ADDRESS LABELS FOR INCENTIVE LETTERS]

-7. REFUSAL

Thank you again. Have a nice (day/evening).

1Note: Graphics courtesy of Dr. Marilyn Townsend and Kathryn Sylva, University of California, Davis.

2Note: Graphics courtesy of Dr. Marilyn Townsend and Kathryn Sylva, University of California, Davis.

3Note: Graphics courtesy of Dr. Marilyn Townsend and Kathryn Sylva, University of California, Davis.

File Type	application/msword
File Title	This attachment provides the instruments for the impact evaluation of the four demonstration projects
Author	scc
Last Modified By	solson
File Modified	2011-03-16
File Created	2011-03-16