Form
Approved OMB No. 0990-0337 Exp.
Date 06/30/2012
Child Exit 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] |
/ / MM DD YY |
If you are a twin, tell us if you are the older or younger twin |
Older twin Younger twin |
Where was your BodyWorks program? Site 1 Site 2 Site 3 [Sites will be entered when chosen] |
1. 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. |
2. How much do you want to make changes to your eating habits? Not at all Very little Some A lot |
3. 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 |
4. How much do you want to make changes to your exercise habits? Not at all Very little Some A lot |
5a. How important to YOU is… |
Not At All Important |
Not Very Important |
Important |
Very Important |
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5b. How important is it to your PARENT/CAREGIVER that you… |
Not At All Important |
Not Very Important |
Important |
Very Important |
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6. 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 |
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7. Do you think you can … |
No, Not At All |
No, Not Really |
Yes, A Little |
Yes, For Sure |
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8. 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 |
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9. A “serving size” is the amount of food you choose to eat for a meal or a snack. True False Don’t know |
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10. 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 |
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11. 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 |
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12. Which are whole grain foods? (Choose one or more.) |
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Brown rice |
Cheese |
Apple juice |
Oatmeal |
Don’t know |
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13. Which sandwich has less fat? |
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Turkey sandwich with mustard |
Tuna salad sandwich |
Don’t know |
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14. How can physical activity help you? (Choose one or more.) |
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Helps you control your weight |
Helps you feel less stressed |
Makes you more confident |
Decreases your vitamin B levels |
Don’t know |
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15. You are taking a walk. You are breaking a sweat, but you can still talk to your friend. This activity is: |
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Light |
Moderate |
Vigorous |
Don’t know |
16. Tell us about the past 7 days. On how many days did you… |
0 Days |
1-2 Day |
3-4 Days |
5-7 Days |
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17. Think about the past 7 days. Did your parent/caregiver encourage you to… |
No |
Yes |
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18. 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 |
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19. During the next month, I plan to… |
Disagree a lot |
Disagree |
Agree |
Agree a lot |
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You’re past the half-way point!
This section asks about your experience with the BodyWorks program.
20. How many sessions did you attend? (Circle one.) 1 2 3 4 5 6 7 8 More than 8 |
21. 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 I did not like the group members I did not finish the homework Other: ___________________________________ |
22a. Below is a list of activities that trainers might have done to encourage people to keep coming to BodyWorks. If your trainer did NOT do this activity, please check “My trainer did NOT do this activity.” If your trainer did these things, please check how much they encouraged you to keep coming to BodyWorks.
How much did it encourage you to keep coming to the BodyWorks sessions when your trainer… |
My trainer DID NOT do this. |
No, Not At All |
No, Not Really |
Yes, A Little |
Yes, A Lot |
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22b. If your trainer gave you prizes to participate in BodyWorks, please describe the prizes you received:
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Just two pages left. You’re doing great!
23. Below is a list of the items in the BodyWorks Toolkit. If you did NOT use a particular toolkit item, please check “I did NOT use this toolkit item.” Please check how helpful they were to you.
How HELPFUL were the following BodyWorks Toolkit Items? |
I did NOT use this toolkit item. |
Not At All Helpful |
Not Very Helpful |
Helpful |
Very Helpful |
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24. How often did you use any of the toolkit items with your parent or caregiver outside of the BodyWorks sessions? Never Once a month Once a week Two or more times a week |
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25. If parts of the BodyWorks Toolkit were not helpful, what could make them better?
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26. My BodyWorks Trainer(s)… |
Disagree a lot |
Disagree |
Agree |
Agree a lot |
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27. Think about the BodyWorks program. How much did you like… |
Did not like at all |
Liked a little |
Liked |
Liked a lot |
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Just one to go!
28. How much did you like the: |
Did not like at all |
Liked a little |
Liked |
Liked a lot |
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29. What would make the BodyWorks program better? (Write your answer in the space below.)
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30a. Within the last 8 weeks, did you go to any education programs about healthy eating or physical activity outside of school time other than BodyWorks?
No Yes
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30b. If you checked “yes,” please describe the program:
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You’re all done! Thank you for your help!!
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0337. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | egolan |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |