Form 0920-20QJ Critical Item Survey

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

T
F
A
R
D
2020

Community Based Survey of Supports
for Healthy Eating and Active Living

Public Reporting burden of this collection of information is estimated to average 5 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 the 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 governments, 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.

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5

Does your local government have a Comprehensive/
General/Master Plan?

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.

¢ Yes
¢ No
3¢
Don’t know
1
2

¢ Yes
¢ No
3¢
Don’t know
1
2

2

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

6

Don’t
No know

A. A land use plan (for new development 1 ¢ 2 ¢
and growth management)
1¢ 2¢
B. A transportation plan
1¢ 2¢
C. A parks and recreation plan
1¢ 2¢
D. A bicycle or pedestrian plan

3

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.

¢

3

¢
¢
3¢
3

¢ Yes
¢ No
3¢
Don’t know
1
2

3

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.

7

¢ Yes, we currently have one
¢ No, 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
1
2

¢ Yes
¢ No
3¢
Don’t know
1
2

4

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

Is the community currently served by public transit
(e.g. buses, light rails, subway commuter rail, etc.)?
¢ Yes
¢ No, but planning for transit
3¢
No, and not planning for transit
4¢
Don’t know
1
2

4