Survey Screenshots

C.2. Screen Shots of CBS Questionnaire

Form Approved
OMB No: 0920-XXXX
Expiration Date: xx/xx/xxxx

Welcome to the Survey of Community-Based
Policy and Environmental Supports for Healthy Eating
and Active Living
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.

Please enter your token identification number in the box below and
click ENTER to begin. This information can be found in your
invitation letter.
Token Identification Number:

Enter

If you experience technical difficulties with the survey, please call the survey contractor (ICF International) toll-free at 1-800-XXX-XXXX
or send an e-mail to our helpbox at [email protected].
Copyright 2012 (ICFI). All rights reserved.

Survey of Community-Based
Policy and Environmental Supports for Healthy Eating
and Active Living
You have been invited to take part in the Survey of Community-Based Healthy Eating Active Living Policy
and Environmental Supports for Healthy Eating and Active Living Pilot Study (CBS Pilot Study), a research
project sponsored by the Centers for Disease Control and Prevention (CDC). The pilot study seeks to
gather information on the policies enacted by local governments to encourage, support, and facilitate
community-level improvements in healthy eating and active living for residents as a part of a
comprehensive national surveillance system. This pilot study is being conducted in 2 states and includes
over 400 local municipalities. The pilot study will ask about the existence of certain policies and standards
that promote more healthful eating and physical activity for residents.
You were identified as the person best able to address questions about the policies enacted by your local
government. Your participation in this study will involve responding to a web-based questionnaire which
will take approximately 60 minutes to complete.
Your participation is voluntary and you may stop participating at any time. You have the right to refuse to
answer any question. Your responses will be treated in a secure manner and will not be disclosed unless
required by law. The information you give us will be combined with the responses of participants in other
staff in other communities in a summary report. The CDC will provide your local government with a brief
summary report that compares the findings from your community with those of similar communities within
your State. There are no risks or benefits to you for participating.
If you have any questions about the study, please call Dr. Deborah Galuska of the CDC at 770-488-6017 or
Dr. Erika Gordon of ICF International at 1-800-XXX-XXXX. A review board at ICF International and CDC
has determined this study to be exempt from the human subjects review process. If you have any
questions about your rights as a study participant, you can call XXXXXX of the CDC at 1-800-XXX-XXXX.
Please click ACCEPT to knowledge that you have read the above consent statement and you would
like to proceed to the survey.
ACCEPT

Copyright 2012 (ICFI). All rights reserved.

Survey of Community-Based
Policy and Environmental Supports for Healthy Eating
and Active Living
Survey Instructions:
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.
As you are completing the survey, you may save your answers after each question. This feature
always you to quit the survey and return at another time to finish completing it. This feature also
always you to save your progress and share the survey url and token identification number with
others within your local government to assist in completing specific questions.
Answers you provide are not final until you click the submit button at the end of the survey. Once
the survey has been submitted, you will no longer be able to access the survey. At the end of the
survey, you will be provided the option to print out the answers you provided prior to submitting it.
Completing the survey is voluntary. No names will ever be reported.

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Copyright 2012 (ICFI). All rights reserved.

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

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?
a. Yes
b. No (GO TO QUESTION 2)
c. I do not understand this question (GO TO QUESTION 2)
d. I tried and could not obtain this information (GO TO QUESTION 2)

BACK

SAVE

Copyright 2012 (ICFI). All rights reserved.

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Survey of Community-Based
Policy and Environmental Supports for Healthy Eating
and Active Living
1A) Was the development of your Comprehensive/ General Plan mandated by the State?
a. Yes
b. No
c. I do not understand this question
d. 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:
a. Land use plan (for new development and growth management)
b. Transportation plan
c. Parks and recreation plan
d. Bicycle or pedestrian plan
e. Our local government does not have any planning documents related to these topics
f. I do not understand this question
g. I tried and could not obtain this information

BACK

SAVE

Copyright 2012 (ICFI). All rights reserved.

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