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pdfAPPENDIX L
YOUTH FOOD BOOKLET
OMB Control Number:
Expiration Date:
The U.S. Department of Agriculture’s
The National Food Study
Youth Booklet
For foods you get when not with a parent or guardian
About the Study
The National Food Study is collecting information from households
throughout the United States. This study will answer questions like:
•
•
•
•
Where do people get their food?
What types of food do people get?
How often do people get food?
How much money do people spend on food?
Your family has agreed to take part in this national study.
Help us make sure that kids count!
We need your help!
First Day: _________________________
Last Day: __________________________
For the next week we want you to keep track of all the foods and
drinks you buy or get for free.
•
Use this book to track foods and drinks that you get when you
are not with a parent or guardian
•
Give your book to your parent or guardian on days 2, 5, and 7
when they call us to report the foods your family got
•
Earn $20 for completing this book
•
Help us to make the National Food Study a big success!
Booklet for: _________________________
Remember … the information that you provide will be kept confidential. Your
name will be removed from your book after it is received. Your answers, and all
the information provided by your household, will be grouped with others.
HOW to USE This Food Book
Follow these easy
STEPS every day!
START a new red page for each place where
get food from outside your home
Remember …
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
WRITE CLEARLY and be careful when writing
numbers
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
DESCRIBE each food and drink that you get
SAVE receipts and tape them to the back
pages
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
√ Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got School cafeteria
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
.
√ Lunch
Dinner/Supper
Snack/drink
√ (√) if free
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Bean & Cheese burrito with salsa &
1
sour cream
Chocolate milk ‐ 1%
1
8 oz.
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Spanish rice
Remember …
1
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
√ Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got McDonalds
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
6 . 9 3
√ Dinner/Supper
Snack/drink
(√) if free
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Amount
paid
Quarter pounder with cheese
1
$3.45
French fries
Large
1
$1.89
Coke
Large
1
$1.59
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Remember …
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Breakfast
$
Lunch
Dinner/Supper
Snack/drink
(√) if free
•
Write down foods and drinks you got ON YOUR OWN when
you were not with your parent or guardian
•
Write each food and drink on a separate line
•
Don’t tell us what you EAT, tell us what you GET!
Ways to Describe Food and Drinks
.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Remember …
Amount
paid
What to look for….
Examples….
√ The BRAND or product
Pepsi, Doritos, Gatorade, Dannon Yogurt
name
√ The TYPE of food
White or whole wheat bread, chicken nuggets or
grilled chicken breast
√ The FORM of the food
Raw carrots or cooked
carrots
√ The FLAVOR
Chocolate milk, oatmeal cookie, or vanilla yogurt
√ The FAT and SUGAR
Whole milk or 1% milk;
regular or diet soda; 100% juice or fruit-flavored
drink
√ Things you ADDED
Butter on bread, ketchup on fries, dressing on salad
Write down the size or weight if it is on the package (such as 12
oz can of soda) and how many you got (such as 2 cookies).
Save receipts in pocket at back page
QUESTIONS? Call 1-866-275-8659
Meals, Snacks, and Drinks
Questions and Answers
Complete one RED page each time you get food or drinks outside your home
(√) DAY you got
food
Mon
Tue
Wed
Thu
Fri
Sat
Sun
A: That’s okay. Some people don’t buy food every day. Did you get
anything for free at school, from your friends, or from any other
place? If yes, write that down.
Name of PLACE
where you got
food:
(√) CHECK the
meal or snack
TOTAL PAID
(including tax)
Q: What if I don’t buy any meals, snacks, or drinks on some
days?
Breakfast
Lunch
Dinner/Supper
Snack/drink
Q: What if all the food I ate came from our kitchen?
A: Then you do not need to write anything in the book for that day.
$
(√) if free
Q: Can I just save my receipts and not write in the book?
.
A: No, because some receipts are hard to read or don’t include all the
information we need. You need to save the receipt and complete
the red page.
Complete this section if you DO NOT have a receipt
or the receipt DOES NOT list each food item
Write size or amount
How
Write each food and drink on a separate line if you know it
many?
(S,M, L or ounces,
grams, lbs, etc.)
Amount
paid
Q: What types of foods and drinks do you want to know
about?
A: All of the food that you and everyone in your household acquire
during the study period. Your parent or guardian will keep track of
groceries and other food that they bring home, and meals and
snacks that they get away from home.
You need to track foods and drinks that you get. Don’t forget the
small items! Sometimes people have just chips or a drink for
lunch—we want to know about that.
Q: Who needs to fill out a booklet?
A: Each person age 11 and older may fill out a booklet. An adult
should write foods acquired by children under age 11.
QUESTIONS? Call 1-866-275-8659
Questions and Answers (continued)
Q: Should I estimate or guess the amount or size?
A: No. Write the amount (for example, the number of ounces or
grams) or the size (for example, small, medium, large) only if it is
listed on a package or menu.
Q: What should I do if someone buys food for me?
A: If someone buys food for you, list the place where they got the food
and write down $0.00 for the total paid since the food was free.
Q: What should I do if I only paid for part of the meal?
A: If you have a receipt but you only paid for part of the meal, circle
the items that you paid for and write the amount that you paid.
SAVE receipts in
pocket
Still have questions? Call us! We’re here to help!
1-866-275-8659
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
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 XXXX-XXXX. The time required to complete this information collection
is estimated to average 53 minutes per week, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The National Food Study is a project of the United States
Department of Agriculture Economic Research Service.
To learn more, go to www.usdafoodstudy.org.
| File Type | application/pdf |
| Author | ECurley |
| File Modified | 2010-09-23 |
| File Created | 2010-08-13 |