0920-20QJ Self-Administered Hardcopy Questionnaire

Form Approved
OMB No.: XXXX-XXXX
Expiration Date: xx/xx/xxxx

2020

Community Based Survey of Supports
for Healthy Eating and Active Living

Public Reporting burden of this collection of information is estimated to average 30 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 CDC/ATSDR
Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; ATTN: PRA 0920-xxxx). Do not return the
completed form to this address.

Instructions for Completing the Booklet
This booklet contains several types of questions.
For some questions, you answer the question by marking a box, like this:
ˆ
¢ Yes
¢ No

1

2

For some questions, you answer the question by filling in one number per box, like this:
ˆ

9

0

Number of Days

You will sometimes be instructed to skip one or more questions.
ˆ
In this example, if your choice is 'No', you skip to question 10; otherwise, you continue to the next
question.

¢ Yes
¢ No → [GO TO QUESTION 10]

1

2

Definitions Definitions
Definitions
For the purposes of this survey, please refer to the definitions below for the following terms.
• Jurisdiction: The geographic territory that is subject to a municipal government
• Local government: The administrative and legal body that oversees a particular jurisdiction
• Community: The people who live within a particular jurisdiction

Consent
On behalf of the Centers of Disease Control and Prevention (CDC), NORC at the University of Chicago (NORC)
is conducting Community-Based Survey for Healthy Eating and Active Living (CBS HEAL). The national
study seeks to gather information on the existence of certain policies, standards, and practices enacted or
implemented by local governments that promote more healthful eating and physical activity for residents.
Your municipality was selected randomly to participate and you were identified as the person best able to
address questions about the policies enacted by your local government. The survey includes questions on
the communitywide planning documents of local government, policies that improve the built environment to
support physical activity, and policies that support increasing access to healthful foods.
The survey will take approximately 30 minutes to complete. Your participation is voluntary. You may choose
not to answer any of the questions or you may choose to not participate without penalty. There are no
expected risks to participating in the survey.
CDC will use this information to evaluate the extent to which local communities have in place policy and
environmental supports for healthy eating and active living consistent with recommendations from expert
groups. In addition, communities, such as yours, may use the data collected to see how they compare with
other communities nationally or with communities of a similar geography, population size, and urban status.

3

Section 1: Structure of Your
Local Government

5

1 ¢
Less

than 5 years ago
years to less than 10 years ago
3 ¢
More than 10 years ago
4 ¢
Currently being revised or updated
5 ¢
It has not been revised or updated
6 ¢
Don’t know
2 ¢
5

The first question asks about the structure of your
local government.
1

Does your local government have a Department, Office,
Division, or other similar entity that is responsible for...?

A. Transportation?
B. Planning?
C. Housing?
D. Parks and Recreation?
E. Health or Public Health?
F. Health Equity

Yes
1 ¢
1 ¢
1 ¢
1 ¢
1 ¢
1 ¢

No
2 ¢
2 ¢
2 ¢
2 ¢
2 ¢
2 ¢

Don’t
know
3 ¢
3 ¢
3 ¢
3 ¢
3 ¢
3 ¢

6

These questions ask about communitywide planning
documents that local governments may have created or
adopted that promote healthy eating and active living.
These may include Comprehensive/General/Master Plans,
or other plans, such as a transportation plan, a parks and
recreation plan, or a bicycle and pedestrian plan.

7

→ [GO TO QUESTION 6]
know → [GO TO QUESTION 6]

3 ¢
Don’t

Was the development of your Comprehensive/General/
Master Plan mandated by the state?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

4

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

Does your local government have any of the following
objectives included in the plan(s)? These objectives should
be written in the plan. However, they do not have to have been
implemented yet.

A. Implementing a Complete Streets policy
(as defined by the National Complete
Streets Coalition) for new and retrofit
projects? A Complete Streets policy,
as defined by the National Complete
Streets Coalition, is a policy ensuring
that transportation planners and
engineers consider the needs of all
users during the design of major road
projects, including bicyclists, pedestrians
of all ages and abilities, public transit
vehicles and riders, and motorists.
B. Developing regulations that promote
street connectivity (for example,
shorter block lengths or adding
pedestrian routes between blocks)
C. Establishing new parks, green spaces, or
recreational walking and bicycling paths
D. Encouraging mixed‑use development
that combines residential land
use with one or more commercial,
institutional, or other public land uses
E. Supporting farmers markets
or community gardens
F. Preserving land for agricultural uses
G. Providing free safe/clean drinking water
in outdoor public places such as parks

1 ¢
Yes

3

Yes
1 ¢

SPECIAL INSTRUCTION: If you answered “No” or “Don’t
know” to Question 2 and 6A‑6E, go to Question 8.

Does your local government have a Comprehensive/
General/Master Plan?
2 ¢
No

Does your local government have any of the following
types of master plans, including stand‑alone plans that
are not a part of the Comprehensive/General/Master Plan?

A. A land use plan (for new development
and growth management)?
B. A transportation plan?
C. A parks and recreation plan?
D. A bicycle or pedestrian plan?
E. A health equity plan

Section 2: Communitywide
Planning Efforts for Healthy
Eating and Active Living

2

When was your Comprehensive/General/Master Plan last
revised or updated?

know

When was your Comprehensive/General/Master Plan
first adopted?
1 ¢
Less

than 5 years ago
2 ¢
5 years to less than 10 years ago
3 ¢
10 years to less than 15 years ago
4 ¢
15 years to less than 20 years ago
5 ¢
More than 20 years ago
6 ¢
Don’t know

4

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

8

Has your local government developed or updated
an Americans with Disabilities Act (ADA) Transition
Plan since 2010? An ADA Transition Plan is a plan local
governments develop to ensure equal access to facilities, public
rights-of-way, and services with people with disabilities.
1 ¢
Yes
2 ¢
No,

but planning to develop or update
and not planning to develop or update
4 ¢
Don’t know
3 ¢
No,

9

11 Does your local government have a formal Complete
Streets policy, as defined by the National Complete
Streets Coalition, for designing and operating streets with
safe access for all users? A Complete Streets policy, as
defined by the National Complete Streets Coalition, is a policy
ensuring that transportation planners and engineers consider
the needs of all users during the design of major road projects,
including bicyclists, pedestrians of all ages and abilities, public
transit vehicles and riders, and motorists.
1 ¢
Yes

Does your local government have a plan for the allocation
of resources to low income or traditionally underresourced areas?
1 ¢
Yes,

we have a stand-alone plan
2 ¢
Yes, it is incorporated into other plans
3 ¢
No, but we are planning to develop one
or incorporate into other plans
4 ¢
No, and we are not planning to develop
one or incorporate into other plans
5 ¢
Don’t know

2 ¢
No

12 What level of government adopted the Complete
Streets policy?
1 ¢
Municipality

2 ¢
Metropolitan
3 ¢
County
4 ¢
Region
5 ¢
Other
6 ¢
Don’t

Section 3: The Built Environment
and Policies That Support
Physical Activity

area (e.g. MPO)

(e.g. regional transportation planning authority)

know

13 When was your Complete Streets policy first adopted?
1 ¢
Less

than 5 years ago
years to less than 10 years ago
3 ¢
10 years to less than 15 years ago
4 ¢
15 years to less than 20 years ago
5 ¢
More than 20 years ago
6 ¢
Don’t know
2 ¢
5

The next questions ask about policies or standards
that support the physical activity of your community’s
residents, even if the policy or standard was passed
by another level of government (such as a regional
transportation planning authority). You may find it helpful
to consult with a representative in either the parks and
recreation department or transportation department if
you cannot answer a question.

14 When was your Complete Streets policy last revised
or updated?
1 ¢
Less

than 5 years ago
years to less than 10 years ago
3 ¢
More than 10 years ago
4 ¢
Currently being revised or updated
5 I¢

It has not been revised or updated
6 ¢
Don’t know
2 ¢
5

10 Does your local government have design standards,
guidelines, or policies that require…

A. Installation of dedicated bicycle
infrastructure for roadway expansion
projects or when retrofitting streets?
B. Developers to reserve space for
use by the local jurisdiction for
development of bicycle infrastructure?
C. Traffic‑calming features (for example,
speed bumps, reduced speed zones,
or signal modifications) that increase
roadway safety in areas with high
pedestrian and bicycle volume
(not including school zones)?

→ [GO TO QUESTION 16]
know → [GO TO QUESTION 16]

3 ¢
Don’t

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

15 Does the Complete Streets policy establish specific
performance measures that will be used to monitor
success? These measures assess the impact of the policy.
Examples include miles of sidewalks or bike lanes completed,
pedestrian or cyclist counts, or pedestrian or cyclist injuries.
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

16 Does your local government have a Vision Zero Action
Plan or Strategy in place, as defined by the Vision Zero
Network? A Vision Zero Action Plan or Strategy, as defined
by the Vision Zero Network, is a plan or strategy to eliminate
all traffic fatalities and severe injuries, while increasing safe,
healthy, equitable mobility for all. Include a plan or strategy
even if it was adopted by another level of government (such as
a regional transportation planning authority).
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

5

know

17 Does your local government have Form‑Based Code
regulations in place, as defined by the Form‑Based Codes
Institute? A Form‑Based Code, as defined by the Form‑Based
Codes Institute, is a land development regulation that fosters
predictable built results and a high‑quality public realm by using
physical form (rather than separation of uses) as the organizing
principle for the code. A form‑based code is a regulation, not a
mere guideline, adopted into city, town, or county law.
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

1 ¢
Yes
3 ¢
Don’t

1 ¢
Outdoor

facilities only
facilities only
3 ¢
Outdoor and indoor facilities
4 ¢
Don’t know
2 ¢
Indoor

23 Does your local government have a pedestrian, bicycle, or
active transportation advisory committee?

know

18 Does your local government have a written requirement
or official objective to install bicycle racks at public
facilities, such as public parks, government buildings,
or transit stations?
2 ¢
No

22 What school recreational facilities are covered by
the joint or shared use agreement or memorandum
of understanding?

1 ¢
Yes
2 ¢
No

24 Is there a designated health/public health or community
representative on the pedestrian, bicycle, or active
transportation advisory committee?

know
A. Health/public health representative
B. Community representative

The next questions ask about parks and outdoor
recreation areas and policies supporting recreation.
19 Does your local government have policies or budgetprovisions related to parks or outdoor recreation
areas, such as…

A. Lighting in parks or outdoor
recreation areas
B. Patrols by police or security in parks
or outdoor recreation areas
C. Maintenance of green
space and equipment
D. Prohibition of unleashed or unrestrained
dogs in parks and outdoor recreation
areas (excluding dog parks)
E. Provision of safe/clean drinking water
fountains or water bottle filling stations
in parks or outdoor recreation areas
F. Maintenance of drinking water fountains
in parks or outdoor recreation areas

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

25 Does your local government have a planning and/or
zoning commission?
1 ¢
Yes
2 ¢
No

→ [GO TO QUESTION 27]
know → [GO TO QUESTION 27]

3 ¢
Don’t

26 Is there a designated health/public health or community
representative on the planning and/or zoning
commission?

A. Health/public health representative
B. Community representative

2 ¢
No

→ [GO TO QUESTION 23]
municipality does not have schools in our
jurisdiction. → [GO TO QUESTION 23]
4 ¢
Don’t know → [GO TO QUESTION 23]
3 ¢
Our

21 Who is your joint use or shared use agreement with?
school district or board
school

2 ¢
Individual
4 ¢
Don’t

Don’t
No know
2 ¢
3 ¢
2 ¢
3 ¢

These next questions ask about zoning and design or
development codes that support healthy eating and
active living.

1 ¢
Yes

3 ¢
Other

Yes
1 ¢
1 ¢

Section 4: Zoning That Supports
Healthy Eating and Active Living

20 Has your local government adopted a joint or shared use
agreement or memorandum of understanding with any school
that allows the public to use school recreational facilities
(for example, gymnasiums, athletic fields, or playgrounds)
during non‑school hours?

1 ¢
Local

→ [GO TO SECTION 4]
know → [GO TO SECTION 4]

3 ¢
Don’t

know
6

Yes
1 ¢
1 ¢

Don’t
No know
2 ¢
3 ¢
2 ¢
3 ¢

27 Does your local government include the following features
in policies for development, including zoning codes
design/development guidelines?

A. Require short‑ to medium
pedestrian‑scale block sizes
B. Require continuous sidewalk coverage
C. Require minimum sidewalk widths of 5 feet
D. Require buildings are oriented to
pedestrian scale (for example, require
entrances or windows face the
street or reduced front setbacks)
E. Require pedestrian amenities such as
trees or furniture along the street
F. Allow mixed land uses (for example,
zoning that combines residential land
use with one or more commercial,
institutional, or public land uses)
G. Require or incentivize accessibility
of safe/clean drinking water
in outdoor public places

31 Does your local government have a defined
process or set of criteria for prioritizing or selecting
transportation projects?
1 ¢
Yes

Don’t
Yes No know
1 ¢
2 ¢
3 ¢
1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

2 ¢
No

32 Does this process include criteria that prioritizes
providing multiple transportation choices (including
non‑motorized modes and transit) for people to access
homes, jobs, schools, food, or other retail?
1 ¢
Yes

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

28 Does your local government have policies that remove
zoning barriers (e.g., lot size requirements) or provide
other zoning incentives to encourage supermarkets to
open in underserved areas or food deserts?

2 ¢
No

3 ¢
Don’t

1 ¢
Yes
2 ¢
No,

but planning for transit → [GO TO QUESTION 35]
and not planning for transit → [GO TO QUESTION 39]
4 ¢
Don’t know → [GO TO QUESTION 39]
3 ¢
No,

34 Does your community have the following types of public
transit available?

A. Bus (e.g. fixed‑route)
B. Light rail
C. Subway or commuter rail
D. Paratransit (e.g., county or
regional van service)
E. Other

2 ¢
No

3 ¢
My

community does not have underserved
areas or food deserts
4 ¢
Don’t know
29 Does your local government have specific zoning policies
to address recurring non‑permanent farmers markets?
1 ¢
Yes
3 ¢
Don’t

know

Section 5: Public Transportation
Policies That Support Healthy
Eating and Active Living
The next questions ask about public transportation and
related policies and processes that support healthy
eating and active living in your community, even if
the policy or process was passed by another level of
government (such as a regional transportation planning
authority).
30 Is transportation planning for your community performed
in part or completely by a regional/metropolitan authority
or organization?
1 ¢
Yes,
2 ¢
Yes,
3 ¢
No

Yes
1 ¢
1 ¢
1 ¢
1 ¢

Don’t
No know
2 ¢
3 ¢
2 ¢
3 ¢
2 ¢
3 ¢
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

35 Are requirements for public transit facilities specified
(e.g., access, lighting, shelter) in community policies
and plans?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

36 Are there multimodal use requirements near transit stops
(e.g., provision of bicycle lanes and sidewalks present
within a certain radius of a transit stop)?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

37 Are there incentives offered to promote transit‑oriented
development (TOD) (e.g., increased density, different
parking requirements)? Transit‑oriented development, or
TOD, is a type of urban development that maximizes the
amount of residential, business, and leisure space within
walking distance of public transportation.

in part
completely

4 ¢
Don’t

know

33 Is the community currently served by public transit (e.g.
buses, light rails, subway commuter rail)?

1 ¢
Yes

2 ¢
No

→ [GO TO QUESTION 33]
know → [GO TO QUESTION 33]

3 ¢
Don’t

1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

7

know

Section 6: Other Policies and
Practices That Support Access to
Healthy Food and Healthy Eating

38 When planning public transit, does your local government
consider locating near the following destinations? Include
planning done by your local government or another level of
government such as the regional transportation planning
authority.

A. Community health clinics,
health hubs, or medical offices
B. Farmers markets
C. Supermarkets or other
full‑service grocery stores
D. Parks or recreation facilities
E. Schools (including
colleges/universities)

The next questions are about policies that may affect
access to healthy food options in your community,
even if the policy or standard was passed by another
level of government. If you feel you cannot provide the
best answer, you may find it helpful to consult with the
following types of representatives within your local
government: a public health official, a representative
in the tax assessor’s office, or a purchasing or
procurement representative.

Do not
have this
destination
in our Don’t
Yes No community know
1 ¢
2 ¢
3 ¢
4 ¢
1 ¢

2 ¢

3 ¢

4 ¢

1 ¢

2 ¢

3 ¢

4 ¢

1 ¢

2 ¢

3 ¢

4 ¢

1 ¢

2 ¢

3 ¢

4 ¢

41 Not including schools, does your local government or
a subcontractor sell foods or beverages to employees
or visitors on local government‑owned or operated
properties? This could include cafeterias, vending machines,
park concession stands, or other food venues.

39 Even if your community is not served by mass transit,
does your local government operate paratransit
community vans or shuttle buses that operate on
as‑needed or on‑demand basis?

1 ¢
Yes
2 ¢
No

42 Not including schools, does your local government have
written nutrition standards for foods and beverages sold
to employees or visitors in or on government‑owned or
operated properties?

1 ¢
Yes
2 ¢
No

→ [GO TO SECTION 6]
3 ¢
Don’t know → [GO TO SECTION 6]
40 Do these vans or shuttle buses provide transportation to
any of the following destinations?

A. Community health clinics,
health hubs, or medical offices
B. Farmers markets
C. Supermarkets or other
full‑service grocery stores
D. Parks or recreation facilities

→ [GO TO QUESTION 44]
know → [GO TO QUESTION 44]

3 ¢
Don’t

Do not
have this
destination
in our
Don’t
Yes No community know
1 ¢ 2 ¢
3 ¢
4 ¢
1 ¢ 2 ¢

3 ¢

4 ¢

1 ¢ 2 ¢

3 ¢

4 ¢

1 ¢ 2 ¢

3 ¢

4 ¢

1 ¢
Yes
2 ¢
No

→ [GO TO QUESTION 44]
know → [GO TO QUESTION 44]

3 ¢
Don’t

43 Are any of these nutrition standards included in food
purchasing agreements and/or food service contracts?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

44 Not including schools, does your local government
or a subcontractor serve food (at little or no cost) to
facility residents or program participants in facilities or
programs owned or operated by the local government?
This could include correctional facilities, senior centers/
programs, recreation programs, or other settings that
serves congregate meals.
1 ¢
Yes
2 ¢
No

→ [GO TO QUESTION 47]
know → [GO TO QUESTION 47]

3 ¢
Don’t

45 Not including schools, does your local government have
written nutrition standards for foods served to facility
residents or program participants in facilities or programs
it owns or operates?
1 ¢
Yes
2 ¢
No

→ [GO TO QUESTION 47]
know → [GO TO QUESTION 47]

3 ¢
Don’t

8

46 Are these nutrition standards included in food purchasing
agreements and/or food service contracts?

In addition to supermarkets and full‑service grocery
stores, food can be sold in smaller venues such as
convenience or corner stores. Some local governments
use incentives, training, or grants to help convenience or
corner stores sell healthier foods.

1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

The next questions ask you about policies that support
increasing access to healthful foods. Supermarkets
and full‑service grocery stores typically stock a higher
proportion of healthier foods than smaller stores,
including convenience and corner stores. Supermarkets
and full‑service grocery stores sell a general line of
foods, including canned and frozen foods; fresh fruits
and vegetables; and fresh and prepared meats, fish, and
poultry.

49 Does your local government provide any of the
following to help convenience or corner stores sell
healthier foods …?

A. Grant or low‑interest loan programs
to purchase equipment for storage
or sales of healthful foods? (e.g.
refrigeration or a point of sales system)
B. Technical assistance or training programs
to increase ability to sell healthier foods
(e.g. support for new point of sales
systems, marketing assistance, produce
handling training, product placement)?
C. Programs to link convenience
or corner store improvements to
broader neighborhood revitalization
projects (improvements to lighting,
signage, safety, walkability)?

47 Does your local government currently use any of the
following approaches to encourage supermarkets and
other full‑service grocery stores to open stores?

A. Tax incentives (for example,
tax abatement, tax credit, or
property tax exemption)
B. Grant or loan programs
C. Programs to link store openings to
broader neighborhood revitalization
projects (for example, improvements to
lighting, signage, safety, or walkability in
the surrounding commercial corridor)

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

SPECIAL INSTRUCTION: If you answered “No” or “Don’t
Know” to Questions 47A‑47C, go to Question 49.

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

SPECIAL INSTRUCTION: If you answered “No” or “Don’t
Know” to Questions 49A‑49C, go to Question 51.
50 Do any of these policies or programs used to help
convenience or corner stores sell healthier foods explicitly
prioritize low‑income or under-resourced areas?
1 ¢
Yes
2 ¢
No

3 ¢
Our

community does not have any
low‑income or under-resourced areas
4 ¢
Don’t know

48 Do any of these policies or programs used by your
community to encourage supermarkets and other
full‑service grocery stores to open stores explicitly
prioritize low‑income or under-resourced areas?

These next questions ask about policies and standards
that your community may use to support access to
farmers markets operated by the local government or
other entities within the community. Please answer
the questions, even if you don’t currently have farmers
markets in your community.

1 ¢
Yes
2 ¢
No

3 ¢
Our

community does not have any
low‑income or under-resourced areas
4 ¢
Don’t know

51 Does your local government have any policies related to
farmers markets, farm stands, or green/produce carts
that…

A. Allow vendors to sell fresh produce
on city‑owned property?
B. Streamline processes for obtaining health
and food safety permits and licenses?
C. Extend waivers of required business
permits or retail licensing fees or taxes?
D. Provide funds or in‑kind services for
personnel, signage, or advertising?
E. Encourage opening in lower income
neighborhoods lacking supermarkets
or full‑service grocery stores?
9

Yes
1 ¢

Don’t
No know
2 ¢
3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

1 ¢

2 ¢

3 ¢

52 Does your community have a farmers’ market, farm stand,
or green/produce cart?
1 ¢
Yes,

we currently have one
but we are working on getting one
3 ¢
No, but we had one or more in the past
4 ¢
No, we have never had one
5 ¢
Don’t know
2 ¢
No,

57 Does your local government offer incentive programs that
allow Supplemental Nutrition Assistance Program (SNAP)
recipients to purchase healthier foods at a subsidized or
discounted rate beyond standard SNAP benefits? (For
example, programs that provide extra SNAP funds for the
purchase of healthy foods in places such as farmers markets,
corner stores, or grocery stores.)
1 ¢
Yes

53 Does your local government provide funding for Electronic
Benefits Transfer (EBT) machines or provide technical
assistance on how to obtain or use EBT machines at
local farmers markets, farm stands, or green/produce
carts? Electronic Benefit Transfer (EBT) is an electronic
system that allows the government to provide assistance
benefits. Assistance benefits include the Supplemental Nutrition
Assistance Program [SNAP], formerly known as Food Stamps,
or the Temporary Assistance for Needy Families [TANF]) via a
plastic debit card to eligible constituents.

2 ¢
No

3 ¢
Don’t

58 Not including schools, does your local government
require testing for lead in tap water in buildings owned or
operated by local government?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

1 ¢
Yes
3 ¢
Our

community does not have a farmers’
market, farm stand, or green/produce cart
4 ¢
Don’t know
54 Does your community have a local, county, or regional
food policy council, food security coalition, or other
community group working to increase access to healthy
food? A food policy council is a council that brings together
stakeholders from diverse food‑related sectors in a specific
geographical area to examine how the food system is operating
in that area and to develop recommendations for improvement.
1 ¢
Yes

→ [GO TO QUESTION 57]
know → [GO TO QUESTION 57]

These next questions ask about policies that support
employee breastfeeding.
59 Federal law requires employers to provide breast‑feeding
employees with break time and a private space other than
a bathroom to pump breast milk. The law applies only
to women who work for hourly wages. Does your local
government have a policy that allows ALL (salaried and
hourly) local government employees break time and space
to pump breast milk?
1 ¢
Yes

3 ¢
Don’t

2 ¢
No

55 Is a local government employee or elected official a
member of the food policy council, food security coalition,
or other community groups working to increase access to
healthy food?
1 ¢
Yes
2 ¢
No

3 ¢
Don’t

know

56 Is there a designated health/public health or community
representative on the food policy council, food security
coalition, or other community groups working to increase
access to healthy food?

A. Health/public health representative
B. Community representative

know

Section 7: Policies That Support
Employee Breastfeeding

2 ¢
No

2 ¢
No

know

Don’t
Yes No know
1 ¢
2 ¢
3 ¢
1 ¢
2 ¢
3 ¢

3 ¢
Don’t

know

60 Does your local government provide paid maternity leave
for its employees? Paid maternity leave is paid leave that
does not use already accrued leave such as vacation or sick
leave. It also does not include leave allowed under the Family
Medical Leave Act (FMLA). A human resources department
representative may be helpful in answering this question.
1 ¢
Yes
2 ¢
No

→ [SURVEY IS COMPLETE]
know → [SURVEY IS COMPLETE]

3 ¢
Don’t

61 How long is this maternity leave?
1 ¢
Less

than 4 weeks
weeks
3 ¢
8‑12 weeks
4 ¢
More than 12 weeks
2 ¢
4‑7

10

Thank you
Thank you for your time and effort in completing this survey. The information you provided will be combined with
the responses of participants in other communities in a summary report that will be sent to you.
If you have any questions about the study, please contact NORC at [email protected] or 800-239-5036.

Mailing Instructions
Please place your completed questionnaire into the enclosed postage-paid returned envelope. If your envelope has
been misplaced, you may mail the questionnaire to:
NORC at the University of Chicago
55 E. Monroe, 19th Floor
Chicago, IL 60603

11

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