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

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix G9. Teen Survey

Summer Meals Survey for Youth 13 through 18 Years

• We want your thoughts!

• We want to know what teenagers 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 with an X, like this: 

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

• Follow the GO TO QUESTION instructions when specified.

1. Are you a boy or a girl?

Boy

Girl

2. How old are you?

___ Years

3. Have you ever gone to the summer meals program at <SITE NAME> at <ADDRESS>?

Yes

No  GO TO SECTION 3

4. How many summers did you go to the summer meals program at <SITE NAME>?

1 summer

2 summers

3 summers

More than three summers

Don’t remember

5. When was the last time you went to the summer meals program at <SITE NAME>?

This summer, 2018

Last summer  GO TO SECTION 3

2 summers ago  GO TO SECTION 3

More than 2 summers ago  GO TO SECTION 3

Don’t remember  GO TO SECTION 3

6. About how many days each week did you go to the summer meals program at <SITE NAME> this summer?

1 day

2 days

3 days

4 days

5 or more days

7. I go to the summer meals program at <SITE NAME> because …

SELECT ONE OR MORE

My friends go here

There are fun things to do

My parents thought it would be good for me

My school teacher thought it would be good for me

I like the food offered at this program

I like the people who work there

I have nowhere else to go

I can get my homework done

Other (PLEASE SPECIFY):

8. Did you eat any meals or snacks at <SITE NAME> this summer?

• Yes

• No  GO TO SECTION 2

9. About how many days each week did you eat a meal or snack served at <SITE NAME> this summer?

1 day

2 days

3 days

4 days

5 or more days

Please turn the page over to complete the survey

10. There are many food choices each day …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

11. There are many food choices during the week …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

12. The food tastes good …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

13. The food looks fresh …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

14. The food smells good …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

15. I enjoy eating meals here …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

16. There is enough food to make me feel full …

All of the time

Most of the time

Some of the time

Hardly ever

Almost never

17. The people serving the food are friendly.

Strongly agree

Agree

Disagree

Strongly disagree

I don't know

18. I like eating at <SITE NAME> because …

SELECT ONE OR MORE

The food is good

I am hungry

I like the different types of foods served

I get to eat with my friends

I get to try different foods

My parents think the food is healthy

I think the food is healthy

Other (PLEASE SPECIFY):

19. Overall, the food served is …

Delicious

Pretty good

Okay

Terrible

20. Would you tell your friends to attend the summer meals program at <SITE NAME> next year?

Yes

Maybe

No

21. Would you like to attend the summer meals program at <SITE NAME> next year?

Yes

Maybe

No

You are done. Thank you for your help.

SECTION 2:

1. Why didn’t you eat meals or snacks at <SITE NAME> this summer?

SELECT ONE OR MORE

The food does not taste good

The food does not look fresh

I am not hungry

I do not like the types of foods served

The people serving the food are not friendly

I do not get to eat with my friends

My parents think the food is not healthy

I think the food is not healthy

The site is not safe

I don’t want to stay at the site to eat

There is no shelter from heat or rain

Other (PLEASE SPECIFY): ______________________

2. Would you tell your friends to attend the summer meals program at <SITE NAME> next year?

Yes

Maybe

No

3. Would you like to attend the summer meals program at <SITE NAME> next year?

Yes

Maybe

No

You are done. Thank you for your help.

SECTION 3:

23. Why didn't you go to the summer meals program at <SITE NAME> this summer, 2018?

SELECT ONE OR MORE

I did not know about the program

I had a job this summer

The program times did not fit my schedule

It was not easy to get there

I went to a different summer program

I didn’t like the activities there

My friends didn’t go there

I didn’t like the facility

I didn’t like the food

I wanted to stay home

The summer food program is for children and teens in need

Other (PLEASE SPECIFY): ______________________

24. Would you like to attend the summer meals program at <SITE NAME> next year?

Yes

Maybe

No

You are done. Thank you for your help.

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.