Traditional Foods SDE Reporting

Traditional Foods SDE Reporting Form – Time 6
Form Approved
OMB No.: 0920-0889
Exp. Date: 06/30/2014
Public reporting burden of this collection of information is estimated to average 2 hours per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining 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 Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-0889)

1

Traditional Foods Shared Data Elements Form
1.

Name of person to contact for questions regarding this submission:
(First, Last Name)

2.

Traditional Food Grantee Name:
Aleutian Pribilof Islands Association, Inc., Alaska
Catawba Cultural Preservation Project, South Carolina
Cherokee Nation, Oklahoma
Confederated Tribes of Siletz Indians, Oregon
Eastern Band of Cherokee Indians, North Carolina
Indian Health Care Resource Center of Tulsa, Oklahoma
Nooksack Indian Tribe, Washington
Prairie Band Potawatomi Nation, Kansas
Ramah Navajo School Board, New Mexico
Red Lake Band of Chippewa Indians, Minnesota
Salish Kootenai College, Montana
Santee Sioux Nation, Nebraska
Sault Ste Marie Tribe of Chippewa Indians, Michigan
Southeast Alaska Regional Health Consortium, Alaska
Standing Rock Sioux Tribe, North/South Dakota
Tohono O'odham Community Action, Arizona
United Indian Health Services, Inc., California

3.

You are reporting on activities held during what six month period?

Months and years of activities

Months

Years

drop-down menu
April to September
…

drop-down menu
2012
…

2

Gardening Activities Across Domains
For the questions below, please consider ALL gardening activities together (across all domains).
4.

Are you reporting on Planting/Gardening?
[Skip pattern: if “no,” skip to question 22]

5.

Which domains were included in Planting/Gardening activities?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

6.

Did Planting/Gardening activities include:
(Please check all that apply.)
Soil preparation (tilling, amending with compost, etc.)
Weeding
Harvesting
Food processing
Other
Describe

3

Community Gardens
7.

Are you reporting on Community garden(s)?
[Skip pattern: if “no,” skip to question 10]

8.

Describe Community garden(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of gardens _______
Total size of gardens in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe ________________________________________________________

9.

Did Community gardens include:
(Please check all that apply.)
Raised beds
Plots
Box garden(s)
Greenhouse

4

School Gardens
10.

Are you reporting on School garden(s)?
[Skip pattern: if “no,” skip to question 13]

11.

Describe School garden(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of gardens _______
Total size of gardens in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

12.

Did School gardens include:
(Please check all that apply.)
Raised beds
Plots
Box garden(s)
Greenhouse

5

Program Gardens
13.

Are you reporting on Program garden(s) (Elders’ gardens, youth gardens, etc.)?
[Skip pattern: if “no,” skip to question 16]

14.

Describe Program garden(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of gardens _______
Total size of gardens in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

15.

Did Program gardens include:
(Please check all that apply.)
Raised beds
Plots
Box garden(s)
Greenhouse

6

Family Gardens
16.

Are you reporting on Family garden(s)?
[Skip pattern: if “no,” skip to question 19]

17.

Describe Family garden(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of gardens _______
Total size of gardens in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

18.

Did Family gardens include:
(Please check all that apply.)
Raised beds
Plots
Box garden(s)
Greenhouse

7

Other Gardens
19.

Are you reporting on Other garden(s)?
[Skip pattern: if “no,” skip to question 22]

20.

Describe Other garden(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of gardens _______
Total size of gardens in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

21.

Did Other gardens include:
(Please check all that apply.)
Raised beds
Plots
Box garden(s)
Greenhouse

8

Permaculture Sites
22.

Are you reporting on Permaculture sites created, developed, or maintained during this six
month reporting period?
[Skip pattern: if “no,” skip to question 24]

23.

Describe Permaculture site(s).
(Please use numbers ONLY except for the “Describe” text box.)
Number of permaculture site(s) _______
Total size of permaculture site(s) in square feet _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

9

Heirloom Seeds
24.

Are you using Heirloom seeds?
[Skip pattern: if “no,” skip to question 26]

25.

Describe Heirloom seeds. __________________________________________

10

Starter Plants
26.

Are you reporting on Starter plants?
[Skip pattern: if “no,” skip to question 28]

27.

Describe Starter plants.
Total number distributed (please put a number in this box) _______
Describe type of starter plants ___________________________________

11

Irrigation
28.

Are you reporting on Irrigation?
[Skip pattern: if “no,” skip to question 30]

29.

Describe Irrigation type (e.g. rainfall, flooding, drip, sprinkler, hose, other, etc.)
_____________________________________________________________________

12

Composting
30.

Are you reporting on Composting?
[Skip pattern: if “no,” skip to question 32]

31.

Describe Composting activities.
(Please use numbers ONLY except for the “Describe” text box.)
How many composting sites were created, developed, or maintained during this six
month reporting period? _______
How many gardens were fertilized with compost? _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

13

Using and Harvesting Produce
32.

Are you reporting on using or harvesting Produce?
[Skip pattern: if “no,” skip to question 34]

33.

What types of produce were used or harvested in this six month reporting period?
Describe produce_________________________________________________
How was produce used? __________________________________________

14

Farmers' Markets
34.

Are you reporting on Farmers’ markets?
[Skip pattern: if “no,” skip to question 38]

35.

Describe Farmers’ markets.
(Please use numbers ONLY except for the “Describe” text box)
Number of days of farmers markets _______
Number of markets _______
Number of vendors/producers _______
Number of community shoppers/consumers _______
Number of vouchers used _______
Describe _________________________________________________

15

Selling Produce
36.

Did Traditional Foods participants sell produce at farmers markets?
[Skip pattern: if “no,” skip to question 38]

37.

Describe produce selling activities.
(Please use numbers ONLY except for the "Type" text box)
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Number of days produce was sold _______
Type(s) of produce sold (describe) ______________________________

16

Other Produce and Traditional Healthy Foods Outlets
38.

Are you reporting on other produce/traditional healthy foods outlets (e.g. health fairs, local
events)?
[Skip pattern: if “no,” skip to question 40]

39.

Describe other produce/traditional healthy food outlets.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes)
Type(s) of produce/traditional foods ______________________________
Type(s) of events ______________________________
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Describe _________________________________________________

17

Healthy Foods Selections in Different Venues
40.

Are Healthy food selections provided in different venues? (e.g. work-site, agency,
supermarket, vending machines, restaurants, etc.)
[Skip pattern: if “no,” skip to question 42]

41.

Describe venues for healthy food selections:
(Please check all that apply.)
Work-site
Agency
Supermarket/market/mini-mart
Vending machines
Restaurants
Other
Describe

18

Incentives, Coupons, and Discounts
42.

Are Incentives, coupons, and discounts available to purchase healthy foods?
[Skip pattern: if “no,” skip to question 44]

43.

Describe incentives, coupons, and discounts.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes)
Type(s) incentives, coupons, discounts ____________________________
Number of distributed (if applicable) _______
Number used this reporting period _______
Describe _________________________________________________

19

Subsistence Activities—Gathering, Fishing, Hunting
44.

Are you reporting on Subsistence Activities?
[Skip pattern: if “no,” skip to question 54]

45.

Which domains were included in your subsistence activities?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

20

Gathering
46.

Are you reporting on Gathering?
[Skip pattern: if “no,” skip to question 48]

47.

Describe Gathering activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of gathering activities _______
Number of activities _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

21

Fishing
48.

Are you reporting on Fishing?
[Skip pattern: if “no,” skip to question 50]

49.

Describe Fishing activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of fishing activities ___________________________________
Number of activities _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

22

Hunting
50.

Are you reporting on Hunting?
[Skip pattern: if “no,” skip to question 52]

51.

Describe Hunting activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of hunting activities _______
Number of activities _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

23

Other Subsistence Activities
52.

Are you reporting on Other subsistence activities (other than gardening, gathering, fishing,
and hunting)?
[Skip pattern: if “no,” skip to question 54]

53.

Describe Other subsistence activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of activities __________________________________________
Number of activities _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe_________________________________________________

24

Storytelling
54.

In the past six months, have your program activities included Storytelling of any type,
including narrative, digital, GIS/posters, etc.?
[Skip pattern: if “no,” skip to question 66]

55.

Which domains were included in your Storytelling activities?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

25

Stories—Narratives, Testimony, and Written Stories
56.

Have your program activities included Narratives, testimony, or written stories?
[Skip pattern: if “no,” skip to question 58]

57.

Describe Narratives, testimony, or written stories.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of narratives, testimony, or written stories _____________________
Number of stories _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

26

Stories—Digital and Photo Stories
58.

Have your program activities included Digital voice, photo voice, or photo, journalism
stories?
[Skip pattern: if “no,” skip to question 60]

59.

Describe Digital voice, photo voice, or photo journalism stories.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of digital voice, photo voice, or photo journalism stories ___________
________________________________________________________
Number of stories _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe ________________________________________________________

27

Stories—GIS, Poster, and Traditional Food Map Stories
60.

Have your program activities included GIS, poster, or traditional food map stories?
[Skip pattern: if “no,” skip to question 62]

61.

Describe GIS, poster, or traditional food map stories.
Describe ________________________________________________________

28

Stories—Music, Plays, and Art Stories
62.

Have your program activities included Music, plays, or art stories?
[Skip pattern: if “no,” skip to question 64]

63.

Describe Music, plays, or art stories.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of music, plays, or art stories ____________________________
Number of stories _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

29

Stories—Other
64.

Have your program activities included Other kinds of stories?
[Skip pattern: if “no,” skip to question 66]

65.

Describe Other kinds of stories.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of Other stories _______
Number of stories _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe _________________________________________________

30

Health Education
Instructions: For the three questions below, health education activities and materials may focus on
a variety of topics, e.g., the importance of healthy foods, the value of traditional foods, the
relationship between food and health/illness, physical activity as a component of health, social
activity as a component of health, etc.
66.

Are you reporting on Health Education activities or materials?
[Skip pattern: if “no,” skip to question 72]

67.

Which domains were included in your health activities or materials?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

31

Health Education Implementation
68.

Have any Health Education activities been implemented in the past six months?
[Skip pattern: if “no,” skip to question 70]

69.

Describe implemented Health Education activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of education provided ___________________________________
Number of times education activity provided _______
Total number of participants for this six month reporting period _______
Of the total number of participants for this six month reporting period, how many
participated for the first time? _______
Describe ________________________________________________________

32

Health Education Materials
70.

Were any new health education materials developed during the last six months?
[Skip pattern: if “no,” skip to question 72]

71.

Describe developed health education materials.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of materials developed ___________________________________
Number of materials distributed _______
Estimated number of persons impacted _______
Describe ________________________________________________________

33

Health Practice (Including Policy) Activities
Instructions: Please note that health policies should be included here, as health practices.
72.

Have any NEW Health Practices (behaviors, resolutions, policies, etc.) been implemented
in the past six months? (For example, incentives to purchase healthy foods, distribution of
affordable traditional foods at farmers' markets, distribution of affordable traditional healthy
foods at community events, composting, safe places for physical activities, inclusion of
gardening in school curricula)?
[Skip pattern: if “no,” skip to question 75]

34

Health Practice Implementation

73.

Which domains are affected by the new health practice(s)?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

74.

Describe health practices implemented.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of health practice implemented (e.g. school, local government, community,
grocery stores, restaurants, other) ___________________________________
_______________________________________________________________
How many new health practices were implemented? _______
Estimated number of persons impacted _______
Describe process - effectiveness, barriers, etc. ____________________________

35

Media Outreach and Materials
75.

Are you reporting on Media Outreach and Materials?
[Skip pattern: if “no,” skip to question 81]

76.

Which domains were included in the media outreach and materials?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

36

Media Outreach Activities
77.

In the past six months, has your program implemented media outreach Activities relating to
any of the three domains (Traditional Foods, Physical Activity, Social Support)?
[Skip pattern: if “no,” skip to question 79]

78.

Describe implemented media outreach.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of media outreach ___________________________________
Number of media outreach events _______
Estimated number of persons impacted _______
Describe _________________________________________________

37

Media Materials
79.

Have any media Materials been developed in the past six months relating to any of the
three domains (e.g., brochures, PSAs, television/radio spots, flyers)?
[Skip pattern: if “no,” skip to question 81]

80.

Describe media materials developed.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of materials developed ___________________________________
Number of materials distributed _______
Estimated number of persons impacted _______
Describe ________________________________________________________

38

Collaboration With Other Agencies And Programs
81.

In the past six months, have you collaborated with other agencies or programs on
activities?
[Skip pattern: if “no,” skip to question 85]

82.

Which domains were included in your collaborative projects?
(Please check all that apply.)
Traditional foods
Physical activity
Social support

39

Collaboration Types and Resources

83.

Describe collaborative activities.
What types of agencies and organizations did you collaborate with (e.g., schools, clubs,
health programs, etc.)? __________________________________________
How many activities involved collaboration with other organizations (number of
collaborations)? (Please use a number to answer this question) _______
Describe ________________________________________________________

84.

What resources were provided by collaborating organizations?
(Please check all that apply.)
Financial Support (e.g. vouchers, funds, etc.)
Staff
Educational Materials
Traditional Foods
Marketing/Media/Outreach (newspaper, radio ads, etc.)
Space

40

Questions Focusing On Specific Domains—Physical Activity
85.

In the past six months, did your program focus on exercise or other physical activities?
[Skip pattern: if “no,” skip to question 90]

86.

Are there places, facilities, or equipment available to conduct physical activities?
[Skip pattern: if “no,” skip to question 88]

87.

Describe availability of places, facilities, or equipment.
(Please write a number in the “number of places” question.)
Number of places, including facilities _______
Describe places and facilities __________________________________________
Describe equipment available __________________________________________

41

Organized Physical Activities
88.

In the past six months, has your program included organized physical activities?
[Skip pattern: if “no,” skip to question 90]

89.

Describe organized physical activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of organized physical activities ___________________________________
Number of organized physical activities _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the
first time? _______
Describe ________________________________________________________

42

Questions Focusing On Specific Domains—Social Support
90.

In the past six months, has your program included activities to provide Social Support for
healthy living?
[Skip pattern: if “no,” skip to question 92]

91.

Describe Social Support for healthy living activities.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of social support activities ___________________________________
Number of social support Activities _______
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the
first time? _______
Describe ________________________________________________________

43

Outcomes for Traditional Foods Activities
92.

In the past six months, did your program measure participant change related to the
production, availability, or use of Traditional Foods (e.g. pre/post questionnaires, follow
cohort, BMI or weight loss measures, testimony that includes participants’ change, other
measures)?
[Skip pattern: if “no,” skip to question 94]

93.

Describe program participant changes traditional foods.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of interventions/activities __________________________________________
Type(s) of methods to measure change ___________________________________
Type(s) of change (attitudes, behavior, skills, knowledge, weight loss, stories,
community activism) ______________________________________________
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Number of participants changed _______
Describe ________________________________________________________

44

Ecological and Environmental Outcomes for Traditional Foods
94.

Were there Ecological or Environmental Traditional Foods change Outcomes in the past six
months (e.g., affordable and available healthy foods)?
[Skip pattern: if “no,” skip to question 98]

95.

Describe Ecological/Environmental traditional foods change Outcomes.
Describe ________________________________________________________

96.

Were the Traditional Foods Ecological/Environmental changes/outcomes designed for
sustainability?
[Skip pattern: if “no,” skip to question 98]

97.

Describe Traditional Foods Ecological/Environmental changes/outcomes designed for
sustainability.
Describe ________________________________________________________

45

Outcomes for Physical Activities
98.

In the past six months, did your program measure participant change related to Physical
Activities (e.g. pre/post questionnaires, follow cohort, fitness or strength measures,
testimony that includes participants’ change, other measures)?
[Skip pattern: if “no,” skip to question 100]

99.

Describe participant change for physical activity.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of interventions/activities __________________________________________
Type(s) of methods to measure change ___________________________________
Type(s) of change (attitudes, behavior, skills, knowledge, weight loss, stories,
community activism) _____________________________________________
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Number of participants changed _______
Describe ________________________________________________________

46

Ecological and Environmental Outcomes for Physical Activity
100.

Were there Ecological or Environmental Physical Activities change Outcomes in the past
six months (e.g., safer walking areas)?
[Skip pattern: if “no,” skip to question 104]

101.

Describe Ecological/Environmental Physical Activity change outcomes.
Describe _________________________________________________

102.

Were the Physical Activities Ecological/Environmental changes/outcomes designed for
sustainability?
[Skip pattern: if “no,” skip to question 104]

103.

Describe Physical Activities Ecological/Environmental changes/outcomes designed for
sustainability.
Describe _________________________________________________

47

Outcomes for Social Support Activities
104.

In the past six months, did your program measure participant change related to Social
Support (e.g. pre/post questionnaires, follow cohort, fitness or strength measures,
testimony that includes participants’ change, other measures)?
[Skip pattern: if “no,” you have reached the end of the survey]

105.

Describe participant change for social support.
(Please use numbers ONLY except for the “Type” and “Describe” text boxes.)
Type(s) of interventions/activities __________________________________________
Type(s) of methods to measure change ___________________________________
Type(s) of change (attitudes, behavior, skills, knowledge, weight loss, stories,
community activism) _____________________________________________
Total number of participants for this six month reporting period _______
Of the participants for this six month reporting period, how many participated for the first
time? _______
Number of participants changed _______
Describe ________________________________________________________

48