Exercise and Food Consumption Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Exercise and Food Consumption Questionnaire

Food consumption

1. When you are making your deliveries in the truck, how often do you eat the following:

Home prepared food Every day 2-3 times/week Once/week Rarely

1 2 3 4

Sit-down restaurants Every day 2-3 times/week Once/week Rarely

1 2 3 4

Fast food restaurants Every day 2-3 times/week Once/week Rarely

1 2 3 4

Food stand/take away Every day 2-3 times/week Once/week Rarely

in truck stops 1 2 3 4

Snack(s) Every day 2-3 times/week Once/week Rarely

1 2 3 4

2. When you are making your deliveries in the truck, how often do you usually drink the following:

Water Every day 2-3 times/week Once/week Rarely

1 2 3 4

Sugared soft drink Every day 2-3 times/week Once/week Rarely

1 2 3 4

Energy drink Every day 2-3 times/week Once/week Rarely

1 2 3 4

Coffee or tea Every day 2-3 times/week Once/week Rarely

1 2 3 4

Fruit juice Every day 2-3 times/week Once/week Rarely

1. 2 3 4

Public reporting burden of 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 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

3. On average, how many servings of fruits and vegetables do you have each week (a serving is 1 cup or about the size of two decks of playing cards)?

More than 3 a day,…………………………………. 1

Three a day,………………………………………… 2

Two a day, 3

One a day, 4

One every other day, 5

One during the past 7 days, 6

Fewer than one a week or none, 7

4. What percentage of your deliveries are you responsible for loading or unloading your cargo during the past 7 days?

__________________ (range from 0 to 100) %