Bodyworks program particpants(ENGLISH & SPANISH Pretest Evaluation)

Form Approved OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

Child Entrance Survey

This survey is important. It asks about the BodyWorks program, your health and your eating and physical activity habits. By taking this survey, you will help us make BodyWorks better. It will take about 20 minutes.

Please read each question before you write your answer. Pick one answer for each question, unless the directions say you can pick more than one. You can skip a question that you do not want to answer. Circle the question number to let us know you skipped it on purpose. This is NOT a test! Be as honest as you can. Your answers are private.

Please write the first and last initials of the parent or caregiver who came with you to this program. [Ex: For Jane Smith, it is J.S. For Jane Doe-Smith, it is J.D.]	__________	__________
	Parent’s First Initial	Parent’s Last Initial

What is your DATE of BIRTH? [Ex: Write 05/22/95 if your birthday is May 22, 1995] If you are a twin, tell us if you are the older or younger twin

/ / mes día año  Older twin  Younger twin

Where was your BodyWorks program?  Site 1  Site 2  Site 3 [Sites will be entered when chosen]

1. How did you hear about BodyWorks? (Choose one or more.)
 Parent or caregiver	 School/Teacher	 Community organization
 Other family member	 Doctor or other health care provider	 Flyer/Brochure
 Friend/Neighbor	 Church, temple, or other place of worship	 Newspaper, TV, or radio ad
 Other _______________________________
2. What made you want to come to the BodyWorks program? I wanted to... (Choose one or more.)  Learn more about healthy eating  Take part in fun physical activities  Improve my health and/or weight  Do an activity with my parent or caregiver  Make new friends  Other:

3. Right now, how do you feel about making changes to your eating habits?

 I have not thought about making any changes.

 I plan to make changes later, maybe in 6 months.

 I want to make changes soon, maybe in the next month.

 I am making changes right now, but this has been for less than 6 months.

 I have made changes and have kept up with them for 6 months or longer.

4. How much do you want to make changes to your eating habits?

 Not at all

 Very little

 Some

 A lot

5. Right now, how do you feel about making changes to your exercise habits?

 I have not thought about making any changes.

 I plan to make changes in the future, maybe in 6 months.

 I want to make changes soon, maybe in the next month.

 I am making changes right now, but this has been for less than 6 months.

 I have made changes and have kept up with them for 6 months or longer

6. How much do you want to make changes to your exercise habits?

 Not at all

 Very little

 Some

 A lot

7a. How important to YOU is…	Not At All Important	Not Very Important	Important	Very Important
Eating healthy foods like fruits, vegetables, whole grains, milk, and meat and beans?				
Exercising for one hour every day?				
Setting goals to improve your eating and physical activity habits?				
Writing in a journal about your eating and physical activity habits?				
Helping your parent or caregiver plan, shop for, or make healthy meals and snacks?				
Preventing diseases that happen later in life, like heart disease, diabetes, and osteoporosis (a disease that causes bones to break more easily)?				

7b. How important is it to your PARENT/CAREGIVER that you…	Not At All Important	Not Very Important	Important	Very Important
Eat a healthy diet?				
Exercise each day for one hour?				
Set goals to improve your eating and physical activity habits?				
Write in a journal about your eating and physical activity habits?				
Help plan, shop for, or make healthy meals and snacks?				

8. Do you want to do what your parents/caregivers want you to do when it comes to…	No, Not At All	No, Not Really	Yes, A Little	Yes, For Sure
Healthy eating?				
Physical activity?				
Setting goals to improve your eating and physical activity habits?				
Writing in a journal about your eating and physical activity habits?				
Helping plan, shop for, or make healthy meals and snacks?				

9. Do you think you can …	No, Not At All	No, Not Really	Yes, A Little	Yes, For Sure
Talk with your family about how you can eat healthier foods or get more physical activity?				
Help plan for, shop, or make healthy meals each week?				
Use nutrition facts labels on packages to pick healthy foods?				
Choose healthy foods and drinks at home?				
Choose healthy foods and drinks at restaurants, including fast food restaurants?				
Plan what physical activities you will do for the week?				
Exercise for one hour every day?				
Exercise even if there are barriers, like if you are too tired or very busy?				
Choose to be active instead of watching TV or sitting at the computer?				
Do bone-strengthening physical activities (running or jumping rope)?				

10. The most important time in life for building strong bones is when you are a/an…

 Baby or young child (ages 0-8)

 Preteen or teen (ages 9-18)

 Young adult (ages 19-29)

 Adult (ages 30 to 54)

 Older adult (age 55+)

 Don’t know

11. A “serving size” is the amount of food you choose to eat for a meal or a snack.

 True  False  Don’t know

12. A “portion” is included on a nutrition facts label and helps you see how many calories are in a serving of food.

 True  False  Don’t know

13. The dangers of unhealthy dieting can be: (Choose one or more.)  Not getting enough nutrients to grow and develop  More risk for weaker bones and osteoporosis later in life  More risk for an eating disorder  Don’t know

14. Which are whole grain foods? (Choose one or more.)

 Brown rice

 Cheese

 Apple juice

 Oatmeal

 Don’t know

15. Which sandwich has less fat?

 Turkey sandwich with mustard

 Tuna salad sandwich

 Don’t know

16. How can physical activity help you? (Choose one or more.)

 Helps you control your weight

 Helps you feel less stressed

 Makes you more confident

 Decreases your vitamin B levels

 Don’t know

17. You are taking a walk. You are breaking a sweat, but you can still talk to your friend. This activity is:

 Light

 Moderate

 Vigorous

 Don’t know

18. Tell us about the past 7 days. On how many days did you…	0 Days	1-2 Day	3-4 Days	5-7 Days
Write in a journal your eating and physical activity habits?				
Work toward goals you set to eat healthy foods and be physically active?				
Help plan healthy meals and snacks?				
Help shop for healthy foods and drinks?				
Help make healthy meals or snacks?				
Eat a healthy breakfast?				
Take a healthy bag lunch to school?				
Eat a meal together with your family?				
Exercise for one hour?				
Exercise with your parent or caregiver?				
Do bone-strengthening exercises (like running or jumping rope)?				
Choose to be active instead of watching TV and/or sitting at the computer?				

19. Think about the past 7 days. Did your parent/caregiver encourage you to…	No	Yes
Eat healthy foods like fruits, vegetables, whole grains, milk, and meats and beans?		
Exercise each day for one hour?		
Set goals to improve your eating and physical activity habits?		
Write in a journal about your eating and physical activity habits?		
Help plan, shop for, or make healthy meals and snacks?		

20. Think about what you eat on an AVERAGE DAY. How many times do you eat or drink…	0 Times	1 Time		2 Times	3 Times		4 Times	5+ Times
Milk or milk products (yogurt, cheese) or milk substitutes (like soy milk or rice milk)?								
Soda or pop?								
Fruits (including 100% fruit juice)?								
Meat or beans (beef, fish, chicken, tofu, egg, peanut butter, cooked beans, nuts, seeds)?								
Chips or French fries?								
Vegetables (including those in soup, stir fry, gumbo, stew, casserole, taco, or omelets)?								
Candy, cookies, cake, or other sweets?								
Grains (bread, cereal, rice, pasta)?								

About You:

21. I am a:  Male  Female

22. How old are you?

 Less than 9 yrs

 9 yrs

 10 yrs

 11 yrs

 12 yrs

 13 yrs

 14 yrs

 More than 14 yrs

23. What grade are you in?

 4th

 5th

 6th

 7th

 8th

 9th

 10th

 Other:______________

24. Are you Hispanic or Latino?  No  Yes

25. What is your race? (Choose one or more.)

 Black/African American

 White

 American Indian or Alaska Native

 Native Hawaiian or other Pacific Islander

 Asian

26a. Did you go to any education programs about healthy eating or physical activity outside of school time in the past 6 months?

 No  Yes

26b. If you checked “yes,” please describe the program: ____________________________________________________

27. How would you describe your eating habits?

 Not at all healthy

 Not very healthy

 Healthy

 Very healthy

28. How would you describe your exercise habits?

 Not at all healthy

 Not very healthy

 Healthy

 Very healthy

You’re all done! Thanks so much for your help!!

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