Respondents- Individuals/Households (Parents/Children/Teens)

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix G8. Child Participant Survey

Summer Meals Survey for Children 5 through 12 Years

PARENTS AND GUARDIANS, PLEASE HELP

YOUR CHILD COMPLETE THIS SURVEY

• We want to know what children your age think of the foods at <site name> at <address>.

• There are no right or wrong answers. Your answers will help make the program better.

• Use black or blue ink to answer.

• Mark your answers in the boxes like this: 

• If you want to change your answer, mark and mark the right answer.

1. Are you a boy or a girl?

Boy

Girl

2. How old are you?

___ Years

3. Did you eat at <SITE NAME> this summer?

Yes

No

Please turn the page over to complete the survey

Tell us what you think about the food at <SITE NAME> this summer

4. This summer, was the food at <SITE NAME> delicious, okay, or terrible?

Delicious

Okay

Terrible

5. This summer, did you feel full after eating the food at <SITE NAME>?

Yes

No

6. This summer, were there different kinds of foods to pick from, at <SITE NAME>?

Yes

No

7. This summer, did the food at <SITE NAME> look good?

Yes

No

8. This summer, did the food at <SITE NAME> smell good?

Yes

No

9. This summer, did the food at <SITE NAME> taste good?

Yes

No

10. What else did you like about the food at <SITE NAME> this summer? ________________________________________________________________

11. What else did you not like about the food at <SITE NAME> this summer?

________________________________________________________________

You are done. Thank you for helping us.

Public reporting burden for this collection of information is estimated to average 20 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: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.