Parent/Student REV 2

Generic Clearance to Conduct Formative Research

D - Student Pre-Survey_FINAL

Parent/Student REV 2

OMB: 0584-0524

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Date: _____________________________ Expiration Date: 04/30/2013

Attachment D – Student Pre-Survey


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[To be read and guided by classroom teacher]

Directions: The following questions ask about foods and nutrition. There is no right or wrong answer, so please be honest.


  1. Yesterday, did you eat any vegetables?

  1. ____ No, I didn’t eat any vegetables

  2. ____ Yes, I ate vegetable 1 time yesterday

  3. ____ Yes, I ate vegetable 2 times yesterday

  4. ____ Yes, I ate vegetable 3 times yesterday

  5. ____ Yes, I ate vegetable 4 times yesterday

  6. ____ Yes, I ate vegetable 5 times yesterday


  1. Yesterday, did you eat any fruit?

  1. ____ No, I didn’t eat any fruit

  2. ____ Yes, I ate fruit 1 time yesterday

  3. ____ Yes, I ate fruit 2 times yesterday

  4. ____ Yes, I ate fruit 3 times yesterday

  5. ____ Yes, I ate fruit 4 times yesterday

  6. ____ Yes, I ate fruit 5 times yesterday

  1. Yesterday, did you eat any beans?

  1. ____ No, I didn’t eat any beans

  2. ____ Yes, I ate beans 1 time yesterday

  3. ____ Yes, I ate beans 2 times yesterday

  4. ____ Yes, I ate beans 3 times yesterday

  5. ____ Yes, I ate benas 4 times yesterday

  6. ____ Yes, I ate beans 5 times yesterday



  1. Yesterday, did you exercise or participate in sports activities (for example, riding your bike, playing soccer or walking to school) that made your heart beat fast or made breath hard for at least 10 minutes.

a ____Yes

b ____No



  1. Please list the 5 vegetable sub-groups:

    1. __________________________

    2. __________________________

    3. __________________________

    4. __________________________

    5. __________________________

Please read the following statements and circle the number that represents how much you agree.

 

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

I am willing to taste new and unusual fruits

5

4

3

2

1

I am willing to taste new and unusual vegetables

5

4

3

2

1

I sometimes think about how far my food travels before it gets to my home/school/community

5

4

3

2

1

I sometimes read the nutrition labels of the foods I eat

5

4

3

2

1

When my parents or caregivers go shopping, I ask them to buy certain fruits and vegetables

5

4

3

2

1

I sometimes prepare foods with my family

5

4

3

2

1

It’s easy to get fruits and vegetables to eat at school

5

4

3

2

1

I try to have at least one fruit or vegetable with every meal

5

4

3

2

1

I sometimes consider where my food comes from when deciding what to eat

5

4

3

2

1

I have tried growing vegetables or fruits at home

5

4

3

2

1

It’s easy to get fruits and vegetables to eat at school

5

4

3

2

1

I enjoy finding and cooking from healthy recipes

5

4

3

2

1



  1. Please read the following statements and circle true or false:

  • All the food sold at my local grocery store comes from inside the state

True

False

  • Half of your plate should be fruit and vegetables

True

False

  • It is important to eat fruits and vegetables that are different colors

True

False


  1. Fill in the blank: Hydration, food, and ______________ all contribute to a balanced body and energy levels.




Mark 2 answers for each.
Circle either A or B; then Circle either C, D or E

I have tried this

I have not tried this

I like this a lot

I like this a little

I don’t like this

Broccoli

A

B

C

D

E

Collard Greens

A

B

C

D

E

Leaf Lettuce

A

B

C

D

E

Mustard Greens

A

B

C

D

E

Spinach

A

B

C

D

E

Swiss Chard

A

B

C

D

E

Winter Squash

A

B

C

D

E

Carrots

A

B

C

D

E

Pumpkin

A

B

C

D

E

Garbanzo Beans

A

B

C

D

E

Corn

A

B

C

D

E

Green Peas

A

B

C

D

E

Potatoes

A

B

C

D

E

Beets

A

B

C

D

E

Chinese Cabbage

A

B

C

D

E

Cucumbers

A

B

C

D

E

Green Beans

A

B

C

D

E

Onions

A

B

C

D

E

Peppers

A

B

C

D

E

Radishes

A

B

C

D

E

Tomatoes

A

B

C

D

E

Turnips

A

B

C

D

E

Strawberries

A

B

C

D

E

Cantaloupe

A

B

C

D

E

Raspberries

A

B

C

D

E



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCMOM Healthy Living Project Pre- Post Questionnaire
AuthorMartha
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File Created2021-01-30
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