English and Spanish Bodywork Program comparison group participant-pretest

Form Approved OMB No. 0990-0337

Exp. Date 06/30/2011

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Parent/Caregiver Entrance Survey

The Office on Women’s Health is trying to find out how well the BodyWorks program helps you, your child, and the rest of your family. You will help improve the program by taking this survey.

This survey will take you about 20 minutes to complete. It includes questions about the BodyWorks program, your eating and physical activity habits, and about your child/children. When the survey asks you about “your child/children,” please think of the child/children who will be participating in BodyWorks as you answer. Unless the directions say otherwise, please choose one response for each question. Your survey answers are private.

Please write down YOUR first and last initials: [Example: Jane Smith is J.S; Jane Doe-Smith is J.D.]

First Initial Last Initial

Please write down the DATE of BIRTH of your child/children who is participating in the BodyWorks Program with you. [Example: Write 05/22/95 if your child’s birthday is May 22, 1995]
Child #1: / / MM DD YY	Child #2 (if applicable): / / MM DD YY	Child #3 (if applicable): / / MM DD YY

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.)
 My child(ren)	 Doctor or other health care provider	 Workplace
 Other family member	 Church, temple, or other place of worship	 Flyer/Brochure
 Friend/Neighbor	 Community organization	 Newspaper, TV, or radio ad
 School/Teacher	 Other _______________________________
2. What made you want to come to the BodyWorks program? (Choose one or more.)  I wanted to learn more about nutrition and/or preparing healthier meals for my family  I wanted to learn more about being physically active  I was concerned about my child/children’s health and/or weight  I was concerned about my own health and/or weight  I wanted to participate in an activity with my child/children  I wanted group support to help me in my efforts to change the way my family eats and exercises  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 2.5 hours per week (which could be 30 minutes each day, done in 10-minute increments)?				
Setting goals to improve your eating and physical activity habits?				
Writing in a journal about your eating and physical activity habits?				
Planning, shopping for, or preparing healthy meals and snacks for your family?				
Preventing diseases that happen later in life, like heart disease, diabetes, and osteoporosis (a disease that causes bones to break more easily)?				

Question 7b is about the child/children that came with you to BodyWorks.

7b. How important is it to you that YOUR child/children is/are…	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 their eating and physical activity habits?				
Writing in a journal about their eating and physical activity habits?				
Helping you plan, shop for, or prepare healthy meals and snacks?				
Eating healthy foods and getting physical activity during childhood and adolescence to prevent diseases later in life, like heart disease, diabetes, and osteoporosis (a disease that causes bones to break more easily)?				

8a. Do you think you can …	No, Not At All	No, Not Really	Yes, A Little	Yes, Definitely
Talk with your family about how you can all eat healthier foods or get more physical activity?				
Provide healthy meals each week (includes planning, shopping, or food preparation)?				
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 2.5 hours per week (which could be 30 minutes each day, done in 10-minute increments)?				
Exercise even if there are barriers, like if you are too tired or very busy?				

Question 8b is about the child/children that came with you to BodyWorks

8b. Do you think you can help your child/children to…	No, Not At All	No, Not Really	Yes, A Little	Yes, definitely
Assist you in providing healthy meals each week (includes planning, shopping, or preparing food)?				
Choose healthy foods and drinks, including foods with calcium and vitamin D?				
Choose healthy foods and drinks at restaurants, including fast food restaurants?				
Limit computer and TV time so your child/children can spend more time being active?				
Exercise for 60 minutes each day, including bone strengthening activities (running or jumping rope and other high-impact activities)				

9. 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
10. A “serving size” is the amount of food you choose to eat for a meal or a snack.  True  False  Don’t know
11. 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
12. 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
13. Which are whole grain foods? (Choose one or more.)
 Brown rice	 Cheese				 Apple juice		 Oatmeal			 Don’t know
14. Which sandwich has less fat?
 Turkey sandwich with mustard				 Tuna salad sandwich					 Don’t know
15. 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
16. 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

17. 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 what you ate and how much physical activity you did?				
Work toward goals you set for yourself /your family to eat healthy foods and be physically active?				
Plan healthy meals for the week ahead, including making a shopping list?				
Shop for healthy foods and beverages for your family?				
Ensure that healthy meals and snacks were prepared for your family?				
Ensure that your family ate healthy breakfasts?				
Eat a meal together with family members?				
Exercise for a total of 30 minutes?				
Exercise with your child/children?				
Ensure that your child/children exercised for one hour?				

18. Thinking 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

19. What is your gender?  Male Female

20. How old are you?

 18 - 21

 22 - 30

 31 - 40

 41 - 50

 51 - 60

 60+

21. Are you Hispanic or Latino?  No  Yes

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

 Black/African American

 White

 American Indian or Alaska Native

 Native Hawaiian or other Pacific Islander

 Asian

23. What is the highest level of education you have completed?

 Elementary school (grades 1-8)

 Some high school (grades 9-11)

 High school degree or GED

 Associate degree (2-year)

 College degree (4-year)

 Graduate degree

24. Please check the category that represents your annual household income.

 Less than $15,000

 $15,000-$34,999

 $35,000-$49,999

 $50,000-$74,999

 $75,000-$99,999

 $100,000-$149,000

 $150,000+

25. Number of children:

 None

 1

 2

 3

 4 or more

26a. Have you participated in any health education programs about nutrition or physical activity 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

 Mostly healthy

 Very healthy

28. How would you describe your exercise habits?

 Not at all healthy

 Not very healthy

 Mostly healthy

 Very healthy

29. How tall are you? __________Feet and inches

30. How much do you weigh? __________Pounds

The following questions are about the child/children that came with you to BodyWorks. If only one child attended BodyWorks with you, please only complete the section labeled “Child #1.”

Child #1:  Girl  Boy

31. What is your relationship to the child who is participating in the BodyWorks program with you?
 Mother or stepmother	 Father or stepfather		 Grandmother or aunt
 Grandfather or uncle	 Other:
32. On average, how many days does your child live with you during the week?  Less than 1 day  1 day  2 days  3-4 days  5-6 days  7 days
33. How old is your child?  9 or less  10  11  12  13  14+		34. What grade is your child in?  4th  5th  6th  7th  8th  9th  10th  Other:____
35. How tall is your child? ____________ Feet and inches		36. How much does your child weigh? ____________ Pounds

Child #2 (if applicable)  Girl  Boy

37. What is your relationship to the child who is participating in the BodyWorks program with you?
 Mother or stepmother	 Father or stepfather		 Grandmother or aunt
 Grandfather or uncle	 Other:
38. On average, how many days does your child live with you during the week?  Less than 1 day  1 day  2 days  3-4 days  5-6 days  7 days
39. How old is your child?  9 or less  10  11  12  13  14+		40. What grade is your child in?  4th  5th  6th  7th  8th  9th  10th  Other:____
41. How tall is your child? ____________ Feet and inches		42. How much does your child weigh? ____________ Pounds

Child #3 (if applicable)  Girl  Boy

43. What is your relationship to the child who is participating in the BodyWorks program with you?
 Mother or stepmother	 Father or stepfather		 Grandmother or aunt
 Grandfather or uncle	 Other:
44. On average, how many days does your child live with you during the week?  Less than 1 day  1 day  2 days  3-4 days  5-6 days  7 days
45. How old is your child?  9 or less  10  11  12  13  14+		46. What grade is your child in?  4th  5th  6th  7th  8th  9th  10th  Other:____
47. How tall is your child? ____________ Feet and inches		48. How much does your child weigh? ____________ Pounds

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-XXXX . The time required to complete this information collection is estimated to average 20 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