Digital Nutrition Education Materials for Middle School Teachers (SLT) - IC 1 of 2

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Name: ________________ Date: _________________ Teacher: _______________Attachment D - Student Survey: Grade 6

Section One: What Do you eat and Drink?

The questions in this section ask about the food you ate over the past week.

Please think about what you ate during the past week, while you were at school, and while you were not at school. Not at school includes all of the rest of the time, for example, when you are at home, at a friend's house, or at a restaurant. You are going to mark the column that shows, on average, how many times you ate the food at school and not at school. If you did not eat this food or drink this beverage during the past week, please mark "never or less than 1 per week."

1a. Type of Drink	Location	Never or less than 1 per week	1 per week	2-4 per week	5-6 per week	1 per day	2-3 per day	4+ per day
Orange juice, apple juice and other 100% juices	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Fruit drinks (such as Snapple, flavored teas, Capri Sun and Kool-Aid)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Sport drinks (such as Gatorade or PowerAde)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Flavored waters such as Propel or vitamin waters	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Unflavored bottled water, tap water, water from a drinking fountain, or other unflavored water	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Diet soda or pop (include all kinds such as Diet Pepsi, Pepsi One, Diet Coke, Diet 7-Up)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Regular soda or pop (include all kinds such as Coke, Pepsi, 7-Up, Sprite, root beer)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Energy Drinks (such as Rockstar, Red Bull, Monster and Full Throttle)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
1% or nonfat milk (sometimes called skim, fat-free, or low-fat milk; includes white and chocolate)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Regular or 2% milk (sometimes called whole, reduced fat, or 4% milk; includes white and chocolate)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐

1b. Type of Food	Location	Never or less than 1 per week	1 per week	2-4 per week	5-6 per week	1 per day	2-3 per day	4+ per day
Low-fat or non-fat potato chips, tortilla chips, and corn chips (such as Baked Lays, Reduced-fat Doritos, Fat-Free Pringles)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Regular potato chips, tortilla chips, corn chips, and puffs (such as Ruffles, Lay's, Pringles, Doritos, Fritos, Cheetos)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Other salty snacks (like cheese nibs, Chex Mix, gold fish crackers, Ritz Bits)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Candy, including chocolate, candy bars, jelly bellies, gummies and Lifesavers (do not include cookies)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Doughnuts, pop tarts, or other breakfast pastries	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Cookies, brownies, pies, and cakes	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Low or nonfat frozen desserts such as low fat ice cream, frozen yogurt, popsicles, & sherbet	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Regular ice cream & milkshakes (include all flavors)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
Whole grain cereals	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
How often did you eat a serving of vegetables such as green salad, peas, green beans, or corn? (do not count fried potatoes or French fries)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
How often did you eat a serving of fruit such as a banana, apple, or grapes? (do not count juices)	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
How often did you eat any breakfast?	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐
How often did you eat breakfast that contained at least 3 food groups?	At School	☐	☐	☐	☐	☐	☐	☐
	Not at School	☐	☐	☐	☐	☐	☐	☐

Section Two: What do you think?

2a. Please list the five food groups below		2b. For each food group at left, please name one common nutrient found in foods from that food group
1) _____________________________		1) _______________________________
2) _____________________________		2) _______________________________
3) _____________________________		3) _______________________________
4) _____________________________		4) _______________________________
5) _____________________________		5) _______________________________

Please describe three healthy breakfast options that include at least 3 different food groups
3a. Name & describe three balanced breakfasts below	3b. Name the food groups in each meal
	Food Group 1	Food Group 2	Food Group 3
Breakfast 1:
Breakfast 2:
Breakfast 3:

4. Attitudes about Breakfast	Strongly Agree	Agree		Disagree	Strongly Disagree
It is difficult for me to find time to eat breakfast every morning.	☐		☐	☐	☐
It is difficult for me to find healthy breakfast options at home.	☐		☐	☐	☐
It is difficult for me to find healthy breakfast options at school.	☐		☐	☐	☐
Eating a balanced, nutritious breakfast can help me focus in class.	☐		☐	☐	☐

In the space below, please describe how you can use MyPlate to build a healthy breakfast:

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