CBS Questionnaire

Form Approved
OMB No: 0920-XXXX
Expiration Date

A ppendix C1.

Survey of Community-Based Policy and Environmental Supports for

Healthy Eating and Active Living

Survey of Community-Based Policy and
Environmental Supports for Healthy Eating and Active Living

Attn: Erika Gordon

Project Director
ICF Macro
11785 Beltsville Drive, Suite 300
Calverton, MD 20705
Tel: (800) XXX-XXXX

Public reporting burden for this collection of information is estimated to average 60 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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D74, Atlanta, GA 30333; ATTN: PRA 0920-XXXX. Do not return the completed form to this address.

Survey of Community-Based Policy and
Environmental Supports for Healthy Eating and Active Living

Healthy eating and active living are important behaviors for the prevention of obesity and other chronic diseases such as heart disease, diabetes, and cancer. The ability to make healthy choices is influenced by one’s surroundings—where one lives, works, shops, and plays. Policies and standards enacted at federal, state, and local levels can influence these surroundings to support healthy eating and active living. To better understand these policies and standards, the U.S. Centers for Disease Control and Prevention (CDC) is conducting this survey of local governments across communities.

This survey asks about select policies enacted in your community by the local government. In this survey, local government generally refers to a municipality, town, or township but not to a county or State. For the purposes of this survey, policies and standards are any written codes or standards, including regulations, ordinances, organizational policy, resolutions, and formal rules.

On average, it will take you 60 minutes to complete the survey. You may need to consult with another person to provide the most accurate and complete information on your local government’s policies and standards. Examples of people to consult with include a tax office or procurement department representative, a parks and recreation department representative, or a transportation department representative. There still may be some questions that are not applicable because of the size of your local community; response options are provided to indicate when a question does not apply.

Completing the survey is voluntary. No names will ever be reported.

SECTION 1. COMMUNITY-WIDE PLANNING EFFORTS FOR HEALTHY EATING AND ACTIVE LIVING

These questions ask about community-wide planning documents that local governments may have created or adopted that promote healthy eating and active living. These may include Comprehensive/General Plans, or other plans such as a transportation plan, a parks and recreation plan, or a bicycle and pedestrian plan.

1. Does your local government have a Comprehensive/General Plan?

1. Yes

2. No (GO TO QUESTION 2)

3. I do not understand this question (GO TO QUESTION 2)

4. I tried and could not obtain this information (GO TO QUESTION 2)

1A. Was the development of your Comprehensive/General Plan mandated by the State?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

2. Does your local government have any of the following types of master plan(s) or other plan(s)? This can include stand alone plans that are not a part of the Comprehensive/General Plan. CHOOSE ALL THAT APPLY:

1. Land use plan (for new development and growth management)

2. Transportation plan

3. Parks and recreation plan

4. Bicycle or pedestrian plan

5. Our local government does not have any planning documents related to these topics (GO TO SECTION 2, PAGE 6)

6. I do not understand this question (GO TO SECTION 2, PAGE 6)

7. I tried and could not obtain this information (GO TO SECTION 2, PAGE 6)

3. Are any of the following objectives included in your local government’s plan(s), even if the objectives have not yet been implemented? CHOOSE ALL THAT APPLY:

Help Statement: A Complete Streets policy, as defined by the National Complete Streets Coalition is a formal multi-step policy ensuring that transportation planners and engineers consistently design and operate the entire roadway with all users in mind- including bicyclists, public transportation vehicles and riders, and pedestrians of all ages and abilities. It includes 10 defined elements.

1. Implementation of a Complete Streets policy (as defined by the National Complete Streets Coalition) for new and retrofit projects

2. Development regulations that promote street connectivity

3. New parks, green spaces, or recreational walking and bicycling paths

4. Encouragement of mixed-use development

5. Support for farmers’ markets or community gardens

6. Agricultural land preservation

7. None of these objectives are included in any of our local government plans

8. I do not understand this question

9. I tried and could not obtain this information

SECTION 2. THE BUILT ENVIRONMENT AND POLICIES THAT SUPPORT PHYSICAL ACTIVITY

The next questions ask about policies or standards that support the physical activity of your community’s residents, even if the policy or standard was passed by another level of government (such as a regional transportation planning authority). You may find it helpful to consult with your city/town planner or a representative in either the parks and recreation department or transportation department if you cannot answer an item.

4. Does your local government have design standards, guidelines, policies or plans that require any of the following? CHOOSE ALL THAT APPLY:

1. Installation of dedicated bike infrastructure for roadway expansion projects or when retro-fitting streets

2. Developer-dedicated right of way to the local jurisdiction for development of bike infrastructure on roadways adjacent to the parcel

3. Traffic calming features (for example, speed bumps, reduced speed zones, or signal modifications) that increase roadway safety in areas with high pedestrian/bicycle volume (not including school zones)

4. Other (specify): __________________________________________________________

(e). Our local government does not have design standards, guidelines, policies or plans

6. I do not understand this question

7. I tried and could not obtain this information

5. Does your local government have a formal Complete Streets policy, as defined by the National Complete Streets Coalition, for designing and operating streets with safe access for all users?

Help Statement: A Complete Streets policy, as defined by the National Complete Streets Coalition is a formal multi-step policy ensuring that transportation planners and engineers consistently design and operate the entire roadway with all users in mind- including bicyclists, public transportation vehicles and riders, and pedestrians of all ages and abilities. It includes 10 defined elements.

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

5. Does your local government have a written requirement or official objective to install bicycle racks at public facilities, such as public parks, government buildings, or transit stations?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

5. Which of the following features are included in your local government’s policies (including zoning codes and design/development guidelines) for new or retrofit development? CHOOSE ALL THAT APPLY:

1. Requiring short to medium pedestrian-scale block sizes (for example, less than 600’ X 600’)

2. Requiring continuous sidewalk coverage

3. Requiring minimum sidewalk widths to promote walking in groups (for example, at least 5 feet wide)

4. Requiring that buildings relate to the street (for example, entrances facing streets, reduced building setbacks, or reduced parking requirements)

5. Requiring that street trees or street furniture separate pedestrian zones from streets

6. Allowing mixed land uses (for example, zoning that combines residential land use with one or more commercial, institutional, or public land uses

7. Other (specify): _________________________________________________________

8. Our local government does not have policies for new or retrofit development

9. I do not understand this question

10. I tried and could not obtain this information

8. Does your local government have any of the following policies or budget provisions related to parks or outdoor recreation areas? CHOOSE ALL THAT APPLY:

1. Lighting in parks or outdoor recreation areas

2. Police or security patrols in parks or outdoor recreation areas

3. Maintenance of green space and equipment

4. Prohibition on unleashed or unrestrained dogs in parks and outdoor recreation areas

5. Prohibition on cars idling in parks or outdoor recreation areas

6. Provision of free drinking water in parks or outdoor recreation areas

7. Other (specify): ________________________________________________________

8. Our local government does not have policies or budget provisions related to parks or outdoor recreation areas

9. I do not understand this question

10. I tried and could not obtain this information

9. Has your local government adopted a joint or shared use agreement or a memorandum of understanding with any school that allows the public to use school recreational facilities (for example, gymnasiums, athletic fields, or playgrounds) during non-school hours?

1. Yes

2. No

3. Our municipality does not have schools in our jurisdiction

4. I do not understand this question

5. I tried and could not obtain this information

10. Does your local government have a planning and/or zoning commission?

1. Yes

2. No (GO TO QUESTION 11)

3. I do not understand this question (GO TO QUESTION 11)

4. I tried and could not obtain this information (GO TO QUESTION 11)

10A. Is there a designated health/public health representative on the planning and/or zoning commission?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

11. Does your local government have a bicycle and/or pedestrian advisory committee?

1. Yes

2. No (GO TO SECTION 3, PAGE 11)

3. I do not understand this question (GO TO SECTION 3, PAGE 11)

4. I tried and could not obtain this information (GO TO SECTION 3, PAGE 11)

11A. Is there a designated health/public health representative on the bicycle and/or pedestrian advisory committee?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

SECTION 3. POLICIES AND PRACTICES THAT SUPPORT ACCESS TO HEALTHY FOOD AND HEALTHY EATING

The next questions are about policies that may affect access to healthy food options in your community. If you feel you cannot provide the best answer, you may find it helpful to consult with the following types of representatives within your local government: a public health official, a representative in the tax assessor’s office, or a purchasing or procurement representative.

11. Does your local government have written nutrition standards for foods sold or served in local government buildings or worksites, including meals, a la carte items, or vending machines? Examples of nutrition standards include provisions for reduced sodium content or for inclusion of fresh fruit and vegetable selections. Do not include public school district or school-level policies in your response.

1. Yes

2. No (GO TO QUESTION 13)

3. I do not understand this question (GO TO QUESTION 13)

4. I tried and could not obtain this information (GO TO QUESTION 13)

12A. Do these standards address any of the following? CHOOSE ALL THAT APPLY:

1. Limiting foods high in added sugar (for example, cookies and candies)

2. Limiting sugar-sweetened beverages (for example, soda, sports drinks, and sweetened tea)

3. Limiting foods high in trans fats

4. Limiting foods high in sodium/salt content

5. Limiting foods high in fat (for example, fried foods)

6. Increasing availability of fruits and vegetables

1. Providing lower calorie options

2. Other (specify):________________________________________________

3. I do not understand this question

7. I tried and could not obtain this information

12B. To which locations do the standards apply? CHOOSE ALL THAT APPLY:

1. Local government facilities that serve foods and beverages to local government employees

2. Local government facilities that serve foods and beverages to the general public

3. Local government facilities that serve foods and beverages to institutionalized persons (for example, prisons, centers for the developmentally disabled)

4. Other (specify):________________________________________________

5. I do not understand this question

6. I tried and could not obtain this information

13. Does your local government have pricing incentives (for example, intentionally pricing less healthy items to be more expensive) to promote the purchase of healthier foods and beverages sold in local government buildings, including cafeterias or vending machines? Do not include public school district or school-level policies in your response.

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

The next questions ask you about policies that support increasing access to healthy foods. Supermarkets and full service grocery stores that sell a general line of food (canned and frozen foods; fresh fruits and vegetables; and fresh and prepared meats, fish, and poultry), typically stock a higher proportion of healthier foods than smaller stores including convenience and corner stores.

14. Does your local government currently use any of the following to encourage supermarkets and other full service grocery stores to open stores? CHOOSE ALL THAT APPLY:

1. Tax incentives (for example, tax abatement, tax credit, or property tax exemption)

2. Grant or loan programs to provide funding to encourage store openings

3. Waivers of certain zoning or ordinance requirements

4. Other (specify): _________________________________________________________

5. Our local government does not have policies or programs that incentivize supermarkets and other full service grocery stores to open in our community (GO TO QUESTION 15)

6. I do not understand this question (GO TO QUESTION 15)

7. I tried and could not obtain this information (GO TO QUESTION 15)

14A. Do any of these policies or programs explicitly prioritize low income or economically depressed areas?

1. Yes

2. No

3. Our community does not have low income or economically depressed areas

4. I do not understand this question

5. I tried and could not obtain this information

15. In addition to supermarkets and full service grocery stores, food can be sold in smaller venues such as convenience or corner stores. Does your local government currently have any of the following programs to help convenience or corner stores sell healthier foods? CHOOSE ALL THAT APPLY:

1. Grant or low-interest loan programs to purchase/upgrade store equipment or furnishings to properly store and sell healthy foods and beverages (for example, fresh produce, low fat milk, or whole grains)

2. Technical assistance or training programs that increase the ability to sell healthier foods (for example, marketing, promotion materials, and/or product placement)

3. Programs to link stores to broader neighborhood revitalization projects (for example, improvements to lighting, signage, safety, or walkability in the surrounding commercial corridor).

4. Other (specify): _________________________________________________________

5. Our community does not provide these types of programs or assistance to convenience or corner stores (GO TO QUESTION 16)

6. I do not understand this question (GO TO QUESTION 16)

7. I tried and could not obtain this information (GO TO QUESTION 16)

15A. Do any of these policies or programs explicitly prioritize low income or economically depressed areas?

1. Yes

2. No

3. Our community does not have low income or economically depressed areas

4. I do not understand this question

5. I tried and could not obtain this information

16. Some residents may not have easy access to supermarkets or full service grocery stores because they do not have access to a car or public transportation, or cannot easily walk to them. Does your local government have a policy that supports dedicated transportation (for example, community vans or shuttle buses) to supermarkets, other full service grocery stores, or farmers’ markets for these residents? Do not include public transportation options in your response.

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

16. Does your local government consider accessibility to supermarkets or other full service grocery stores in their assessment of public transportation routes?

1. Yes

2. No

3. Our community does not have public transportation

4. I do not understand this question

5. I tried and could not obtain this information

18. Does your local government have any of the following policies related to farmers’ markets, farm stands, or green/produce carts? CHOOSE ALL THAT APPLY:

1. Operating a farmers’ markets or allowing the sale of fresh produce on city property

2. Offering streamlined processes for obtaining health and food safety permits and licenses

3. Extending waivers of required business permits or retail licensing fees or taxes

4. Encouraging or incentivizing fresh food vending locations in areas lacking supermarkets and full service grocery stores

5. Providing funds or in-kind services for personnel, signage, or advertising

6. Other (specify):__________________________________________________________

7. Our community does not have a farmers market, farm stand, or green/produce cart

8. I do not understand this question

9. I tried and could not obtain this information

18. Does your local government provide funding for Electronic Benefits Transfer (EBT) machines or provide technical assistance on how to obtain or use EBT machines at local farmers’ markets, farm stands, or green/produce carts?

Help Statement: Electronic Benefit Transfer (EBT) is an electronic system that allows the government to provide assistance benefits (such as the Supplemental Nutrition Assistance Program [SNAP] or the Temporary Assistance for Needy Families [TANF]) via a plastic debit card to eligible constituents.

1. Yes

2. No

3. Our community does not have a farmers’ market, farm stand, or green/produce cart

4. I do not understand this question

5. I tried and could not obtain this information

20. Does your jurisdiction have a local or regional food policy council, food security coalition, or similar entity?

Help Statement: A food policy council is a council that brings together stakeholders from diverse food-related sectors in a specific geographical area to examine how the food system is operating in that area and to develop recommendations for improvement.

1. Yes

2. No (GO TO QUESTION 21)

3. I do not understand this question (GO TO QUESTION 21)

4. I tried and could not obtain this information (GO TO QUESTION 21)

20A. Is someone from the local government a member on it?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

20B. Is there a designated health/public health representative on the food policy council, food security coalition, or similar entity?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

20. Federal law requires that employers provide hourly wage women who are nursing with break time and a private place to express breast milk. Does your local government have a policy that extends this provision to salaried employees?

1. Yes

2. No

3. I do not understand this question

4. I tried and could not obtain this information

22. Does your local government provide paid maternity leave for its employees?

Help Statement: Paid maternity leave is paid leave that does not use already accrued leave such as vacation or sick leave. It also does not include leave allowed under the Family Medical Leave Act (FMLA).

1. Yes

2. No (GO TO SECTION 4, PAGE 18)

3. I do not understand this question (GO TO SECTION 4, PAGE 18)

4. I tried and could not obtain this information (GO TO SECTION 4, PAGE 18)

22A. How long is this maternity leave?

1. Less than 4 weeks

2. 4-7 weeks

3. 8-12 weeks

4. 3 months or more

SECTION 4. CONCLUDING INFORMATION

The last set of questions asks about your experience in completing the pilot survey. CDC would like to obtain a greater understanding of the types of local government staff who provided input for completion of the instrument and the level of effort required. The completion of these items is optional, but your responses are important as they will play a critical role in refining the pilot survey for use in a more comprehensive surveillance system.

23. Including yourself, how many staff members in your local government were asked to contribute a response to this survey? __________________ Number of respondents

23. Please list the individuals that have contributed by their job titles (not their names) and a reference to the specific survey section or questions that they were involved in completing.

Job Title:		Question(s)/ Section(s):
Job Title:		Question(s)/ Section(s):
Job Title:		Question(s)/ Section(s):
Job Title:		Question(s)/ Section(s):

23. How would you describe the level of effort required to complete the survey?

1. Required an extremely high level of effort (for example, required multiple sittings and consultation with more than 3 or 4 additional staff, or additional research to locate answers)

2. Required a high level of effort (for example, required some dedicated time and consultation with additional staff to complete)

3. Required a moderate level of effort

4. Required a minimal level of effort

26. How long in total did it take to complete the survey? ______________ Minutes

27. Of the items you answered, what data would be most useful for improving your local government’s ability to support community-level improvements in healthy eating and active living for residents?

28. If you have any additional comments about the pilot survey, please share your comments below.

THANK YOU FOR COMPLETING THIS SURVEY