Shared data elements - screen shots

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Foods Data Sharing Element Form
Form Approved
OMB No.: 0920-xxxx
Exp. Date: mm/dd/yyyy
Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining 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
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Foods Data Sharing Element Form
The purpose of this form is to collect shared data elements from each ‘traditional foods’ grantee. Each reporting period is
for six months. Data will be aggregated by CDC across all grantees each six months. Grantees can request individual
reports for their respective programs. Contact info. - Email:mvf9@cdc.gov - Phone: 505-232-9907 - Yahoo Group Link:
click here
Survey Monkey Guidelines/Instructions
Welcome to Survey Monkey (SM) for the Traditional Foods and Sustainable Ecologies project! These guidelines are to assist you with the SM
data entry tool.
1) The data source to populate SM is your local evaluation data only. SM is not meant to be an environmental scan of your community, but to
reflect the evaluation data you have gathered for your Traditional Foods and Sustainable Ecologies program.
2) You are NOT expected to populate every question or domain. Only enter relevant local evaluation data collected for each reporting period.
3) Some of your local data may not “fit” SM. Highlights of these data can be reported in your meeting presentations and yearly continuation
application.
4) Please have your ‘Traditional Foods’ Shared Data Elements Excel spread sheet available as you navigate SM. The spread sheet provides
the whole SM layout.
5) There are three domains to report activities: Traditional Foods, Physical Activities, and Social Support. Please determine which main
domain best fits the primary purpose of your respective activities. Each domain is for activities not reported in other domains.
6) In the chosen domain, check the radio button to report on that domain only. If the main domain activity includes activity types of another
domain(s), check the respective button(s). Please include a brief description of these activities under the main domain(s) activity section. To
prevent double-counting, theses activities will not be counted separately.
7) Please aggregate your data numerically over the 6 month reporting period. You can enter SM at different times to enter data. If you choose
to report monthly, for example, please add the numerical data each time to create a cumulative sum for each activity. Upon completion, your
entries will reflect six months of information. All data will be retained over the reporting period.
a. For the total number of participants in each section, please provide the total number of all participants over the six month reporting period.
b. Of that total number of participants over six months of activities, please provide how many were participating for the first time.
8) All data will be cleared at the same time for every six month reporting period, so it is critical to enter data on time. You will have six weeks
following each reporting period to enter all you activities for the respective reporting period.
9) When you have completed data entry for the reporting period, please contact us to download your data. Please let us know if you would like
your local SM data returned to you in an excel spreadsheet.

1. Name of person to contact for questions regarding this submission:
(First, Last Name)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Foods Data Sharing Element Form
2. Traditional Food Grantee Name
j
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n

Aleutian Pribilof Islands Association, Inc., Alaska

j
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n

Catawba Cultural Preservation Project, South Carolina

j
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m
n

Cherokee Nation, Oklahoma

j
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m
n

Confederated Tribes of Siletz Indians, Oregon

j
k
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m
n

Eastern Band of Cherokee Indians, North Carolina

j
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m
n

Indian Health Care Resource Center of Tulsa, Oklahoma

j
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m
n

Nooksack Indian Tribe, Washington

j
k
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m
n

Prairie Band Potawatomi Nation, Kansas

j
k
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m
n

Ramah Navajo School Board, New Mexico

j
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m
n

Red Lake Band of Chippewa Indians, Minnesota

j
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n

Salish Kootenai College, Montana

j
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n

Santee Sioux Nation, Nebraska

j
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m
n

Sault Ste Marie Tribe of Chippewa Indians, Michigan

j
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n

Southeast Alaska Regional Health Consortium, Alaska

j
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n

Standing Rock Sioux Tribe, North/South Dakota

j
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n

Tohono O'odham Nation, Arizona

j
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n

United Indian Health Services, Inc., California

3. You are reporting on activities held in what month?
(Fiscal Year)
j
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n

First 6 months (Oct - March)- 2010/2011

j
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m
n

Second 6 months (April - Sept)- 2011

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
4. Reporting on Traditional Foods Domain only:
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
5. Reporting on Traditional Foods Domain(s):

Traditional Food Domain
includes Physical Activity
Traditional Food Domain
includes Social Support

Yes

No

j
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m
n

j
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n

j
k
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m
n

j
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m
n

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional foods/alternative healthy foods - Activities

6. Are you reporting on Planting/Gardening?

j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
7. Are you reporting on community garden(s)?
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
8. Type of community garden(s):
c
d
e
f
g

Raised Beds

c
d
e
f
g

Plots

c
d
e
f
g

Box garden(s)

c
d
e
f
g

Greenhouse

c
d
e
f
g

Other

Other (please specify)

5

6

9. Community Garden(s)
Number of gardens
Total size of garden(s)square feet
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
10. Are you reporting on school garden(s)?
j
k
l
m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
11. Type of school garden(s):
c
d
e
f
g

Raised Beds

c
d
e
f
g

Plots

c
d
e
f
g

Box garden(s)

c
d
e
f
g

Greenhouse

c
d
e
f
g

Other

Other (please specify)

12. School Garden(s)
Number of gardens
Total size of garden(s)square feet
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
13. Are you reporting on program garden(s)? (e.g. Elders' garden, youth garden, etc.)
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
14. Type of program garden(s):
c
d
e
f
g

Raised Beds

c
d
e
f
g

Plots

c
d
e
f
g

Box garden(s)

c
d
e
f
g

Greenhouse

c
d
e
f
g

Other

Other (please specify)

15. Program Garden(s)
Number of gardens
Total size of garden(s)square feet
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Food Section
16. Are you reporting on Individual/Family garden(s)?
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
17. Type of Individual/Family garden(s):
c
d
e
f
g

Raised Beds

c
d
e
f
g

Plots

c
d
e
f
g

Box garden(s)

c
d
e
f
g

Greenhouse

c
d
e
f
g

Other

Other (please specify)

18. Individual/Family Garden(s)
Number of gardens
Total size of garden(s)square feet
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
19. Are you reporting on Starter Plants?
j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
20. Starter Plants
Type (describe)
Total Number Distributed

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
21. Are you reporting on composting?
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
22. Composting
How many composting sites
How many gardens
fertilized
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Community/Individual Gardens Production and Distribution of Produce

23. Produce
Type(s) of produce
Describe
How produce used describe

24. Farmers Market Availability
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
25. Farmers Market Availability
Number of days of farmers
markets
Number of markets
How often held
Number of
vendors/producers
Number of community
shoppers/consumers
Number of vouchers used
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
26. Traditional foods participants in farmers markets
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
27. Traditional foods participants in farmers markets
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Number of days sold
produce
Type(s) of produce sold
(describe)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
28. Other produce/traditional healthy foods outlets (e.g. health fairs, local events)
Type(s) of
produce/traditional foods
Type(s) of events
How often events held
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
29. Health Policy Implemented (e.g. distribution of affordable traditional foods at farmer
markets, distribution of affordable traditional healthy foods at community events)
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
30. Health Policy Implemented (e.g. distribution of affordable traditional foods at farmer
markets, distribution of affordable traditional healthy foods at community events)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date(s) implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional foods/alternative healthy foods - Activities

31. Gathering
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
32. Traditional foods/alternative healthy foods - Activities
Type
Number of activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional foods/alternative healthy foods - Activities

33. Fishing
j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
34. Traditional foods/alternative healthy foods - Activities
Type
Number of activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional foods/alternative healthy foods - Activities

35. Hunting
j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
36. Traditional foods/alternative healthy foods - Activities
Type
Number of activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional foods/alternative healthy foods - Activities

37. Other(s) - not listed
j
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n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
38. Traditional foods/alternative healthy foods - Activities
Type
Number of activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Storytelling for traditional foods or alternative healthy foods - Activities

39. Stories: narratives/testimony/written stories
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
40. Stories: narratives/testimony/written stories
Type(s) of story
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
41. Stories: digital voice/photo voice/photo journalism
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
42. Stories: digital voice/photo voice/photo journalism
Type(s) of story
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
43. Stories: GIS traditional foods maps
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
44. Stories: GIS traditional foods maps
Describe (e.g. type(s) of
foods, time frame)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
45. Stories: music/plays/art
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
46. Stories: music/plays/art
Type(s) of story
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
47. Other kinds of traditional foods stories:
j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
48. Other kinds of traditional foods stories:
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Healthy foods selections in different venues

49. Are healthy food selections provided in different venues? (e.g. work-site, agency,
supermarket, vending machines, restaurants, etc.)
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
50. Are healthy food selections provided in different venues? (e.g. work-site, agency,
supermarket, vending machines, restaurants, etc.)

Check all that apply:
c
d
e
f
g

Work-site

c
d
e
f
g

Agency

c
d
e
f
g

Supermarket/Market/Mini-mart

c
d
e
f
g

Vending Machines

c
d
e
f
g

Restaurants

c
d
e
f
g

Other

Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
51. Are incentives, coupons, discounts available to purchase healthy foods?
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
52. Are incentives, coupons, discounts available to purchase healthy foods?
Type(s) incentives,
coupons, discounts
Number distributed (if
applicable)
Number used this reporting
period
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
53. Health Policy Implemented (e.g. affordable, lower cost of healthy food; prohibit sale
of less healthy foods, incentives to purchase healthy foods)
j
k
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m
n

Yes

j
k
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
54. Health Policy Implemented (e.g. affordable, lower cost of healthy food; prohibit sale
of less healthy foods, incentives to purchase healthy foods)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional Healthy Foods Education

55. Traditional Healthy Foods Education Activity
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
56. Traditional Healthy Foods Education Activity
Type(s) of education
How often education
activity provided
Total Number of
participants trained
Total Number of new
participants trained
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
57. Traditional foods health education materials developed
j
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
58. Traditional foods health education materials developed
Type(s)
Number distributed
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
59. Health Policy Implemented (e.g. health education about traditional foods in
schools/after school programs)
j
k
l
m
n

Yes

j
k
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
60. Health Policy Implemented (e.g. health education about traditional foods in
schools/after school programs)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Traditional Foods Media and Outreach

61. Traditional Foods Media Outreach
j
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n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
62. Traditional Foods Media Outreach
Type(s) of media/outreach
Number of media/outreach
events
Est. number persons
impacted
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
63. Traditional Foods Media materials developed
j
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m
n

Yes

j
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n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
64. Traditional Foods Media materials developed (brochures, psas, television/radio
spots, flyers)
Type(s) of materials
Number distributed
Est. Number persons
impacted
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Collaboration with other agencies and programs

65. Traditional foods collaboration with other agencies and programs
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
66. Collaborative agency/program/dept/organization
Describe

67. Type of traditional foods collaboration
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
68. Co-sponsored traditional foods events with other agencies and programs
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
69. Co-sponsored traditional foods events with other agencies and programs
Number of events this
reporting period
Number of total co-sponsors
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
70. Success of the traditional foods co-sponsor/collaborations
Success of the cosponsor/collaborations

not successful

somewhat successful

successful

very successful

N/A

j
k
l
m
n

j
k
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m
n

j
k
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m
n

j
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m
n

j
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m
n

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
Outcomes for traditional local healthy foods activities

71. Did the program measure participant change (e.g. pre/post questionnaires, follow
cohort, BMI measures, weight loss measures, testimony that includes participants
change, other measures)?
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
72. Participant traditional foods change outcomes (e.g. behavior, skills, knowledge,
weight loss, stories)
Type(s) of
interventions/activities
Type(s) of methods to
measure change
Type(s) of change
(behavior, skills, knowledge,
weight loss, stories)
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Number of participants
changed
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
73. Ecological/Environmental traditional foods change outcomes (e.g. affordable and
available healthy foods)
j
k
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m
n

Yes

j
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Food Section
74. Ecological/Environmental traditional foods change outcomes (e.g. affordable and
available healthy foods)
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
75. Are the traditional foods environmental changes/outcomes designed for
sustainability?
j
k
l
m
n

Yes

j
k
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m
n

No

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Traditional Local Healthy Foods Section
76. Are the traditional foods environmental changes/outcomes designed for
sustainability?
Describe

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Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
77. Reporting on Physical Activity Domain only?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 71

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
78. Reporting on Physical Activity Domain(s):

Physical Activity Domain
includes Traditional Foods
Physical Activity Domain
includes Social Support

Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 72

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Availability of places for/and physical activities

79. Are there places/equipment available to conduct physical activities provided through
the grant action plan?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 73

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
80. Places/Facilities/Equipment
Number of
Places/Facilities/Equipment
Describe

Page 74

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
81. Does the grant action plan include organized physical activities?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 75

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
82. Grant action plan include organized physical activities
Type(s)
Number of Physical
Activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 76

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
83. Health Policy Implemented (e.g. safe places for physical activities, extra curricular
physical activity in schools as a result of the grant action plan)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 77

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
84. Health Policy Implemented (e.g. safe places for physical activities, extra curricular
physical activity in schools as a result of the grant action plan)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

Page 78

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Community/Individual Gardens Physical Activities

85. Participants time in garden (plowing, planting, watering, weed pulling, harvesting)
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Total participants' time in
garden (hr/min)
Describe gardening
activities

Page 79

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
86. Health Policy Implemented (e.g., inclusion of student gardening in physical
education curricula, as extra credit in core curricula for science, math, etc.)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 80

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
87. Health Policy Implemented (e.g., inclusion of student gardening in physical
education curricula, as extra credit in core curricula for science, math, etc.)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

Page 81

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Storytelling for physical activities

88. Stories: narratives/testimony/written stories
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 82

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
89. Stories: narratives/testimony/written stories
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 83

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
90. Stories: digital voice/photo voice/photo journalism
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 84

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
91. Stories: digital voice/photo voice/photo journalism
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 85

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
92. Stories: GIS physical activity maps
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 86

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
93. Stories: GIS physical activity maps
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe type(s) of physical
activity

Page 87

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
94. Stories: music/plays/art
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 88

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
95. Stories: music/plays/art
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 89

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
96. Other kinds of physical activity stories
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 90

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
97. Other kinds of physical activity stories
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 91

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Physical Activity Health Education

98. Physical Activity included in Health Education Programs
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 92

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
99. Physical Activity included in Health Education Programs
Type(s) of education
Number of education
activity provided
How often education
activity provided
Total Number of
participants trained
Total Number of new
participants trained
Describe

Page 93

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
100. Health education materials developed that are focused on physical activity
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 94

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
101. Health education materials developed that are focused on physical activity
Type(s)
Number distributed
Describe

Page 95

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
102. Health Education Policy Implemented (e.g. school policy for physical activity and
education)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 96

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
103. Health Education Policy Implemented (e.g. school policy for physical activity and
education)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

Page 97

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Physical Activity Media and Outreach

104. Physical Activity Media/Outreach
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 98

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
105. Physical Activity Media/Outreach
Type(s) of media/outreach
Number of media/outreach
events
Est. number persons
impacted
Describe

Page 99

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
106. Physical Activity Media (brochures, psas, television/radio spots, flyers)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 100

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
107. Physical Activity Media Materials Developed
Type(s) of materials
Number distributed
Est. number of persons
impacted
Describe

Page 101

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Collaboration with other agencies and programs

108. Physical activity collaboration with other agencies and programs
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 102

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
109. Collaborative agency/program/dept/organization
Describe

110. Type of physical activity collaboration
Describe

Page 103

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
111. Co-Sponsored physical activity events with other agencies and programs
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 104

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
112. Physical activity co-sponsored events
Number of co-sponsored
event this reporting period
Number of total co-sponsors
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 105

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
113. Success of the physical activity co-sponsor/collaborations
Success of the cosponsor/collaborations

not successful

somewhat successful

successful

very successful

N/A

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 106

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
Outcomes for physical activity activities

114. Did the program measure participant change (e.g. pre/post questionnaires, follow
cohort, BMI measures, weight loss measures, testimony that includes participants
change, other measures)?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 107

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
115. Participant physical activity change outcomes (e.g. behavior, skills, knowledge,
weight loss, stories)
Type(s) of
interventions/activities
Type(s) of methods to
measure change
Type(s) of change
(behavior, skills, knowledge,
weight loss, stories)
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Number of participants
changed
Describe

Page 108

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
116. Ecological/Environmental physical activity change outcomes (e.g. safer walking
areas)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 109

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
117. Ecological/Environmental physical activity change outcomes (e.g. safer walking
areas)
Describe

Page 110

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
118. Are the physical activity environmental changes/outcomes designed for
sustainability?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 111

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Physical Activity Section
119. Are the physical activity environmental changes/outcomes designed for
sustainability?
Describe

Page 112

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
120. Reporting on Social Support Domain Only?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 113

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
121. Reporting on Social Support Domain(s):

Social Support Domain
includes Traditional Foods
Social Support Domain
includes Physical Activity

Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 114

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
Social Support Activities (e.g. talking circles, healthy food pot lucks, lifestyle coaches)

122. Are there planned/available activities to provide social support for healthy living?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 115

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
123. Social Support for healthy living activities
Type(s)
Number of activities
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 116

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
124. Health Policy Implemented (e.g. talking circles for breastfeeding mothers, Eagle
Book talking circles)
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 117

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
125. Health Policy Implemented (e.g. talking circles for breastfeeding mothers, Eagle
Book talking circles)
Type(s) of health policy
(e.g. school, local
government, community,
grocery store, restaurants,
other)
Number of policies
Date implemented
Describe process
(effectiveness, barriers,
limitations, sustainability)

Page 118

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
Storytelling for social support

126. Stories: narratives/testimony/written stories
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 119

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
127. Stories: narratives/testimony/written stories
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 120

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
128. Stories: digital voice/photo voice/photo journalism
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 121

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
129. Stories: digital voice/photo voice/photo journalism
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 122

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
130. Stories: music/plays/art
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 123

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
131. Stories: music/plays/art
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 124

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
132. Other kinds of social support stories
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 125

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
133. Other kinds of social support stories
Type(s) of stories
Number of stories
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 126

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
Collaboration with other agencies and programs

134. Social support collaboration with other agencies and programs
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 127

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
135. Collaborative agency/program/dept/organization
Describe

136. Type of social support collaboration
Describe

Page 128

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
137. Co-sponsored social support events with other agencies and programs
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 129

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
138. Co-sponsored social support events with other agencies and programs
Number of co-sponsored
events
Number of total co-sponsors
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Describe

Page 130

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
139. Success of the social support co-sponsor/collaborations
Success of the cosponsor/collaborations

not successful

somewhat successful

successful

very successful

N/A

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 131

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
Outcomes for social support activities

140. Did the program measure participant change (e.g. pre/post questionnaires, follow
cohort, BMI measures, weight loss measures, testimony that includes participants
change, other measures)?
j
k
l
m
n

Yes

j
k
l
m
n

No

Page 132

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
Social Support for Healthy Living Section
141. Participant social support change outcomes (e.g. behavior, skills, knowledge,
weight loss, stories)
Type(s) of
interventions/activities
Type(s) of methods to
measure change
Type(s) of change
(behavior, skills, knowledge,
weight loss, stories)
Total Number of
participants for this 6 month
reporting period
Of the total number of
participants for this 6 month
reporting period, how many
participated for the first
time?
Number of participants
changed
Describe

Page 133

Traditional Foods Shared Data Elements Reporting Form - revised Sept.
THE END OF SURVEY
Thank you for completing the survey.

Page 134