2 My Habits Pre-Post test

Evaluation Instruments: Set 2 O.M.B 0925-0491

Exp. XX/XX

My Habits Pre-Test and Post Test

_{CHAN Training Using the Your Heart, Your Life Manual}

My Habits Pre and Post-Tests were used for the Jackson, Pearl and Bolton CHAN trainings. The tests measured lifestyle (behavioral) changes before and after the training. We may be able to compare behavior changes before and after training each group. In addition, we may be able to compare and contrast behavior changes among the three groups.

Public reporting burden for this collection of information is estimated to average 6-15 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0491). Do not return the completed form to this address.

Jackson Heart Study Community Partnership

Community Health Advisor Network Cardiovascular Training

My Habits Pre-Test Behavior

Date _____/____/_______ Location:_________________________ CHA ID:____________

First Name:______________________________ Last Name: _________________________

Salt & Sodium
How often do you do the following? Please CIRCLE the number corresponding to 1=Never, 2=Sometimes, 3=Usually, 4=Not Certain or 5=Always	Never	Sometimes	Usually	Not Certain	Always
1. Buy fresh vegetables.	1	2	3	4	5
2. Buy frozen vegetables.	1	2	3	4	5
3. Buy canned vegetables.	1	2	3	4	5
4. Buy fresh garlic.	1	2	3	4	5
5. Buy garlic powder.	1	2	3	4	5
6. Buy garlic salt.	1	2	3	4	5
7. Choose foods labeled low sodium, sodium free or not salt added.	1	2	3	4	5
8. Add salt to the water when cooking beans, rice, pasta and vegetables.	1	2	3	4	5
9. Use smoked, cured and processed beef, pork and poultry like bologna, ham and sausage.	1	2	3	4	5
10. Use a salt shaker at the table.	1	2	3	4	5
11. Fill the salt shaker with a mixture of herbs and spices.	1	2	3	4	5
12. Choose fruits and vegetables instead of salty snacks like chips and fries.	1	2	3	4	5

Cholesterol & Fat
How often do you do the following? Please CIRCLE the number corresponding to 1=Never, 2=Sometimes, 3=Usually, 4=Not Certain or 5=Always	Never	Sometimes	Usually	Not Certain	Always
1. Drink 1% or fat free milk.	1	2	3	4	5
2. Eat fat free or low fat cheese.	1	2	3	4	5
3. Use canola, olive, safflower, soybean or sunflower oil when cooking.	1	2	3	4	5
4. Use lard in preparing food.	1	2	3	4	5
5. Read the food label to help you choose foods lower in fat, saturated fat and cholesterol.	1	2	3	4	5
6. Trim the fat from beef before cooking.	1	2	3	4	5
7. Take the skin and fat from chicken before cooking.	1	2	3	4	5
8. Cook ground meat and drain the fat.	1	2	3	4	5
9. Cool soups and remove the layer of fat that rises to the top.	1	2	3	4	5
10. Choose fat free or low fat salad dressing, mayonnaise and sour cream.	1	2	3	4	5
11. Use small amounts of margarine instead of butter.	1	2	3	4	5
12. Choose fruits and vegetables instead of high fat foods like cookies or fries.	1	2	3	4	5

Weight
How often do you do the following? Please CIRCLE the number corresponding to 1=Never, 2=Sometimes, 3=Usually, 4=Not Certain or 5=Always	Never	Sometimes	Usually	Not Certain	Always
1. Read labels to choose foods lower in calorie.	1	2	3	4	5
2. Bake chicken, beef or fish instead of frying it.	1	2	3	4	5
3. Eat a variety of foods in a meal. Example: have vegetables and rice with a piece of skinless chicken instead of 3 pieces of fried chicken alone.	1	2	3	4	5
4. Drink regular soda or sweetened powdered drinks.	1	2	3	4	5

Physical Activity
How often do you do the following? Please CIRCLE the number corresponding to 1=Never, 2=Sometimes, 3=Usually, 4=Not Certain or 5=Always	Never	Sometimes	Usually	Not Certain	Always
1. Do 30 minutes of activity each day at once or in three 10-minute periods.	1	2	3	4	5
What Do You Do To Be More Active?
2. Walk	1	2	3	4	5
3. Play sports	1	2	3	4	5
4. Hike	1	2	3	4	5
5. Work in the garden.	1	2	3	4	5
6. Work out in the gym.	1	2	3	4	5
7. Swim	1	2	3	4	5
8. Other activities, please list:

Alcohol
How often do you do the following? Please CIRCLE the number corresponding to 1=Never, 2=Sometimes, 3=Usually, 4=Not Certain or 5=Always	Never	Sometimes	Usually	Not Certain	Always
1. Do you drink alcohol?	1	2	3	4	5
2. If you drink alcohol, please list what you drink:
3. How often do you drink alcohol? a. Rarely, on special occasions b. Occasionally - once a month c. Once per week d. Regularly - several times a week e. Daily

DEMOGRAPHIC BACKGROUND

We would like to know a little about yourself in order to help us to understand who is likely to become a Community Health Advisor (CHA).

1. What is your age group?

[ ] under 35 years [ ] 35 to 44 [ ] 45 to 54 [ ] 55 to 64

[ ] 65 & older

2. What is your ethnicity?

[ ] Hispanic [ ] Non-Hispanic

3. What is your race?

[ ] Black or African American [ ] White/ Caucasian

[ ] American Indian or Alaska Native [ ] Asian

[ ] Native Hawaiian or Other Pacific Islander

4. What is your current marital status?

[ ] Married [ ] Divorced / Separated [ ] Single [ ] Widowed

5. How many adults (18 and older) live in your household? [ ] [ ]

6. How many children 12 - 17 live in your household? [ ] [ ]

7. How many children under 5 live in your household? [ ] [ ]

8. Are you responsible for the care of an elderly or chronically ill relative?

[ ] No [ ] Yes Who? _____________________________

9. What is your gender?

[ ] Male [ ] Female

10. What is the highest year of school that you completed?

Never went to school ....................... 0

Eleventh grade or less ...................... 1

Graduated High School or GED....... 2

Some College................................... 3

Bachelors Degree............................. 4

Graduate School............................... 5

Doctorate/Professional Degree......... 6

11. Would you say your health is?

Excellent........................................... 1

Very Good........................................ 2

Good................................................. 3

Fair................................................... 4

Poor.................................................. 5

12. What is the main reason you want to become a Community Health Advisor (CHA)?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your help in completing this useful information!

My Habits Pre-Test Behavior_v09201004