Digital Nutrition Education Materials for Middle School Students (Individuals/Households) - IC 2 of 2

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Attachment D_Student Survey Grade 6 Final

Digital Nutrition Education Materials for Middle School Students (Individuals/Households) - IC 2 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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