Form 0917-0036 Community Nutrition

Form Approved

OMB Form No. 0917-0036

Expiration Date: January 31, 2022

Community Nutrition: Gardening Presentation

Date ________________ TOPIC: ________________________________________

Age: __ 5 years and younger __ 18 – 34 years __ 65 years and older

__ 6 – 17 years __ 35 – 64 years

Gender: __ Male __ Female

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Unsure Agree Strongly

Disagree Agree

1. I would recommend Community Nutrition to my family and friends 1 2 3 4 5

2. Usually my health is good 1 2 3 4 5

3. I am sure I can take care of my own health (T’áá hwó ájít’éego) 1 2 3 4 5

4. The presenter/educator was knowledgeable about related gardening information 1 2 3 4 5

5. How confident do you feel you will practice the gardening techniques from this

workshop at home? 1 2 3 4 5

6. Because I have a garden/farm:

I eat more fruits and vegetables 1 2 3 4 5

I spend less money on food 1 2 3 4 5

I am more physically active 1 2 3 4 5

7. What gardening practice, if any, do you intend to use as a result of what you have learned in this workshop? ____________________________________________________________________________________

Comments/Suggestions: ___________________________________________________________________

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COMMUNITY NUTRITION STAFF ONLY

Presenter’s Name: ­­­­­­­­­­­­­­______________________________

Facilitator’s Name: ­­­­­­­­­­­­­­______________________________

__ Healthy Weight __ Food Accessibility __ Breastfeeding Rev. 03/7/17

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.