Bodyworks program particpants(English & Spanish Participant Exit Survey-Post Only Pilot Study)

Form Approved OMB No. 0990-xxxx

Exp. Date xx/xx/xxxx

Participant Exit Survey

Tell us what you think about BodyWorks!

This survey is being used to get your feedback about the BodyWorks program. There are no right or wrong answers. Please take your time and answer each question based on what you really think. Please do NOT put your name on this survey. Your answers are private.

Today’s Date: ____ ____ / ____ ____ / ____ ____

Participation In BodyWorks

1. Where did you take your BodyWorks Program?

Location City State

(Name of School, Community Center, Organization)

2. I am a:

 Child/Teen BodyWorks Participant

 Parent/Caregiver BodyWorks Participant

 Other:

3. About how many BodyWorks sessions did you attend?

 1  2  3  4  5  6  7  8  More than 8

4. If you missed one or more sessions, what were the reasons? (Choose one or more)

 I was busy with something else (for example: responsibilities at school, work, or home)

 I was sick

 I did not have a ride (transportation)

 I did not like the location

 I did not like the group members

 I did not finish the homework

 Other (please specify):

Below is a list of things that trainers might have done to encourage people to keep coming to BodyWorks. If your trainer did these things, please check how much they encouraged you to keep coming to BodyWorks. If your trainer did NOT do this activity, please check “My trainer did NOT do this activity.”

How much did it encourage you to keep coming to the BodyWorks sessions when your trainer…	My trainer did NOT do this activity.	Not At All	Some	A Lot
Contacted you before a session to remind you to attend?				
Contacted you when you missed a session?				
Gave you prizes such as coupons, gift cards, water bottles, or t-shirts				
Paid for you or your family to get a ride to BodyWorks?				
Provided babysitting while you attended BodyWorks sessions?				
Other (please specify):				

Below is a list of the items in the BodyWorks Toolkit. Please check how helpful they were to you. If you did NOT use a particular toolkit item, please check “I did NOT use this toolkit item.”

How HELPFUL were the following BodyWorks Toolkit Items?	I did NOT use this toolkit item.	Not At All Helpful	Somewhat Helpful	Very Helpful
Body Basics				
Family Food and Fitness Journal				
Best Journal Ever! for girls				
Bodyworks DVD				
Weekly Planner				
Recipe Book				
Shopping List				
BodyWorks For Teens				
BodyWorks For Guys				

Please check how much you liked these parts of your BodyWorks program?

Did you like…?	No	Kind Of	Yes
Where the BodyWorks sessions were held?			
When the BodyWorks sessions were held?			
How long each of the BodyWorks sessions lasted?			
How many BodyWorks sessions were offered?			

Please check how much you agree with these descriptions of your BodyWorks program.

Thinking about the BodyWorks program…	No	Kind Of	Yes
The activities were interesting.			
The activities were fun.			
I liked the session topics.			
I liked the healthy snacks.			
I liked the physical activities or “energizers.”			
I felt comfortable in the group.			
I would recommend it to a friend.			

Please check how much you agree with these descriptions of your BodyWorks trainer.

My BodyWorks Trainer(s)…	No	Kind Of	Yes
Showed up on time.			
Was well prepared for each session.			
Knew a lot about the topics we discussed.			
Made me feel comfortable in the group.			
Treated me with respect.			
Connected well with the group.			
Included everyone in activities.			
Managed any problems that arose.			

Please check how much BodyWorks helped you in these areas.

The BodyWorks program has helped me to…	No	Kind Of	Yes
Better understand healthy eating.			
Better understand my physical activity needs.			
Feel that eating a healthy diet is important.			
Feel that regularly exercising is important.			
Feel more confident about making healthy food choices.			
Feel more confident about exercising.			
Feel more confident talking about nutrition and physical activity with my family.			
Eat healthy, even when there are barriers in my way.			
Be physically active, even when there are barriers in my way.			

Please check how much LESS or MORE you do these activities after being in BodyWorks.

Because you participated in the BodyWorks program, how much LESS or MORE do you now…?	LESS Than Before	About the SAME	MORE Than Before
Participate in physical activities?			
Make healthy food choices?			
Set/work toward physical activity and/or healthy eating goals?			
Write in a journal about my eating and/or physical activity habits?			

Please check how much you plan to continue these habits. If you did NOT make any changes in your habits because of BodyWorks, please check “I did NOT make any changes.”

In the next MONTH, I plan to continue the…	I did NOT make any changes.	NO	Maybe	YES
Healthier eating habits that I began as a result of BodyWorks.				
Physical activity habits that I began as a result of BodyWorks.				

Please write about what would make the BodyWorks program better.

13. What would make the BodyWorks program better? (Write your answer in the space below.)

Are you?

 Male  Female

What is your age?

9 Years Old and Under  16 – 19 Years Old  50 - 59 Years Old

 10 – 12 Years Old  20 - 29 Years Old  60 - 69 Years Old

 13 – 15 Years Old  30 - 39 Years Old  70 + Years Old

 16 – 19 Years Old  40 - 49 Years Old

Are you Hispanic or Latino?

 No  Yes

What is your race? (Choose one or more)

 Black/ African American

 White

 American Indian or Alaskan Native

 Native Hawaiian or other Pacific Islander

 Asian

About You

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