Form 11 School Food Environment Instrument

SSA ATTACHMENT 18

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

SCHOOL NUTRITION ENVIRONMENTAL ASSESSMENT

PROTOCOL FOR FOOD ENVIRONMENT QUESTIONNAIRE

The following document contains the school nutrition environmental assessment protocol that will be followed to obtain information on the school food environment for each school from which the sample of children/families was recruited. District-level Food Service Director/Manager for each district from which these schools were recruited will be contacted by NORC and asked to complete a web-based survey on each recruited school’s food environment.

SCHOOL FOOD ENVIRONMENT QUESTIONNAIRE FOR D Public reporting burden for this collection of information is estimated to average 30 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 (0925-0649). Do not return the completed form to this address. ISTRICT FOOD SERVICE DIRECTOR/MANAGER

Please complete this questionnaire about the following school: Name of school [PRE-LOADED SCHOOL NAME] You may need to consult other school staff to complete all of the questions. This survey should take about 5-10 minutes to complete for each school.

/ / mm dd yyyy

Today’s Date

School ID [PRE-LOADED]

____________________________________ Position of individual completing form

Is this an elementary school (some combination of grades K-6), a middle/junior high school (some combination of grades 5-9) or some other kind of school? Elementary 1 Middle or Junior High 2 Other 3 Specify grades:___________________

1.

Is this the first year that this school has been open?

Yes 1 No (SKIP TO Q5) 2

If this is the first year that this school has been open, please answer questions 2-4 with regard to the present school year.

2.

How many students in this school are approved for free meals for the present academic year at this school?

# students

3.

How many students in this school are approved for reduced price meals for the present academic year at this school?

# students

4.

How many total students are enrolled at this school for the present academic year?

# students SKIP TO Q.10

Please answer the following 5 questions (questions 5-9) for the last academic school year (that is the one prior to the present school year).

5.

How many total lunches (including full price, reduced price, and free meals) were claimed for the last academic year at this school?

# lunches

6.

How many total breakfasts (including full price, reduced price and free meals) were claimed for the last academic year at this school?

# breakfasts

7.

How many students in this school were approved for free meals for the last academic year at this school?

# students

8.

How many students in this school were approved for reduced price meals for the last academic year at this school?

# students

9.

How many total students were enrolled at this school for the last academic year?

# students

10.

Is the campus open (students are allowed to leave) at lunch for: Please  only one.

All students 1 Some students 2 No students 3

11.

For how many years has this school participated in the following (write “1” if this is the first year the school is participating; write “0” if this school is not participating):

a.

The federally funded Fresh Fruit and Vegetable program?

# years

b.

The Department of Defense (DoD) Fresh program?

# years

c.

The State Farm to School Program?

# years

d.

USDA’s Team Nutrition Initiative

# years

e.

Healthier US School Challenge

# years Bronze # years Silver # years Gold

f.

Other state or Federal food or nutrition program: No other program……(SKIP TO Q12)…….0 Name of program:_______________________ Don’t remember name………………………-2

# years

12.

During the last academic school year (or current year if this is the first year of the school), about what percent of reimbursable school lunch entrées at this school were prepared using the following methods?

a.

Convenience prep [Pre-portioned, heat and serve items, i.e. frozen burrito]

%

b.

Minimal prep [Food preparation primarily involving assembling and portioning, i.e. chef’s salad made with pre-cut and pre-cooked ingredients]

%

c.

School-made/scratch prep [food preparation involving the use of raw ingredients, some degree of ingredient prep, and cooking when needed, i.e. spaghetti with scratch-prepared sauce]

%

IF Q1=1, SKIP TO Q15.

13.

Has the amount of scratch and minimal preparation cooking that has been done at this school been increasing or decreasing? Please  only one.

Increasing 1 Decreasing 2

14.

Over how many years has this trend in scratch and minimal preparation cooking occurred?

# years

15.

To what extent have each of the following components of the local wellness policy (a district or school policy to encourage healthy eating and physical activity among students) been implemented at this school and for how many years have they been in place? For example, if 10-50% of the policy component related to reimbursable school meal goals has been implemented, select To Some Extent and then enter the number of years it has been implemented in this manner. Please note that if you are selecting “To a limited extent or not at all” please enter in the number of years this has been the situation.  For example, if the policy component has not been in place at all and the school has been open for 12 years, please select that answer option and then enter the number 12 for the number of years.

Please  only one.

Policy Component

To a limited extent or not at all (<10% implemented)

To some extent (10-50% implemented)

To a large extent (51-90% implemented)

Completely (>90% implemented)

Number of years in place

Reimbursable school meal goals

1

2

3

4

Nutrition guidelines for all other foods sold (competitive foods) such as a la carte, school store, vending, etc.

1

2

3

4

Nutrition guidelines for foods that are not sold, but offered, such as at classroom parties and social events

1

2

3

4

IF Q1=1, SKIP TO Q17.

16.

To what extent have there been changes to the following within the last 10 years at this school: (Choose one response for each item and estimate when the changes started, if applicable.)

Please  only one.

If ’d, please fill in last column

Did not change

Got worse

Somewhat improved

Improved a lot

Since __ years ago

Meal offerings

0

1

2

3

Meal facilities

0

1

2

3

Competitive foods

0

1

2

3

17.

Any additional comments or explanations:

No comments…………..0

SCHOOL FOOD ENVIRONMENT QUESTIONNAIRE FOR

DISTRICT FOOD SERVICE DIRECTOR/MANAGER

Sources and References

1. U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS). School Nutrition Dietary Assessment (SNDA) Study III, Pre-Visit Questionnaire and Menu Survey – Reimbursable Meals Form. Retrieved on November 14, 2010 from http://www.fns.usda.gov/oane/MENU/Published/CNP/cnp.htm

2. USDA Team Nutrition School Wellness Policy Demonstration Project (SWDP), 2009. Questionnaire on Local Wellness Policy: School Level, 2^nd wave. Not published.

3. Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). School Health Policies and Practices Study (SHPPS). Retrieved on November 16, 2010 from http://www.cdc.gov/HealthyYouth/shpps/2006/questionnaires/index.htm

4. School Nutrition Association: http://docs.schoolnutrition.org/trendsetters/trendsets/blasts/trendSETS_Newsletter_june.htm, posted 7/9/2008, accessed 2/2011