Impact Evaluation Instruments - Households

Appendix A.

Data Collection Instruments

For Impact Evaluation

Instruments for the Iowa Nutrition Network Impact Evaluation

English Version

OMB No. 0584-XXXX

Expiration date: XX/XX/20XX

See OMB statement on inside cover

Post-Survey: Intervention Group

Thank you for taking part in this important study!

Please fill out and return the survey in the enclosed envelope within the next week.

If you have any questions about the What Does Your Child Eat? study, please send an e‑mail to USDA@sna.rti.org or call toll-free at 1-866-800-9176.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-XXXX). Do not return the completed form to this address.

If you have questions regarding your rights as a research participant, you may contact RTI’s Office of Research Protection toll-free at 866-214-2043.

This survey asks about what your child eats. You may recall that we asked some of the same questions in the last survey. This study is being sponsored by the U.S. Department of Agriculture’s Food and Nutrition Service and conducted by RTI International, a nonprofit research organization. The survey will take about 15 minutes to complete. You will receive $15 for completing this survey.

All of your answers to the survey will be kept private. We will not share your answers with anyone, except as required by law. You may skip any questions you do not want to answer. If you have any questions, please call Matthew Bensen at RTI at 1-866-800-9176.

Questions on Whether Certain Foods Are Available at Home

1. Were any of these foods in your home during the past week? Include fresh, frozen, canned, and dried foods. (Circle Yes or No for each food.)

a. Bananas	Yes	No
b. Apples	Yes	No
c. Grapes	Yes	No
d. Raisins	Yes	No
e. Pears	Yes	No
f. Celery	Yes	No
g. Carrots	Yes	No
h. Cucumbers	Yes	No
i. Broccoli	Yes	No
j. Zucchini	Yes	No
k. Potato chips, tortilla chips, corn chips, or other chips	Yes	No
l. Regular soft drinks or sodas	Yes	No

Questions on the Fruits and Vegetables Your Child Eats

For the next questions, think about what your child ate during the past week, or the past 7 days. Do NOT include food eaten at school, before/after school care, or day care.

1. How many days during the past week did your child eat more than one kind of fruit each day? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

3. Think about what your child ate during the past week. About how many cups of fruit did your child eat on a typical day? Do NOT include fruit juice. (Circle one.)¹

   1. None
   2. ½ cup
   3. 1 cup
   4. 1 ½ cups
   5. 2 cups	None		1 cup		2 cups		3 cups
   6. 2 ½ cups
   7. 3 cups or more

4. How many days during the past week did your child eat more than one kind of vegetable each day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

5. Think about what your child ate during the past week. About how many cups of vegetables did your child eat on a typical day? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

   1. None
   2. ½ cup
   3. 1 cup
   4. 1 ½ cups
   5. 2 cups	None		1 cup		2 cups		3 cups
   6. 2 ½ cups
   7. 3 cups or more

6. During the past week, did your child eat any meals or snacks that were provided by his/her school, before school care program, after school care program, or day care? (Circle all that apply.)

1. No, did not eat breakfast, lunch, or snacks provided by school, before or after school care program, or day care

2. Yes, breakfast

3. Yes, lunch

4. Yes, snacks

7. Is your child willing to try a new kind of fruit? Do NOT include fruit juice. (Circle one.)

1. No

2. Maybe

3. Yes

8. How many days during the past week did you give your child fruit for a snack? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

9. How many days during the past week did you give your child fruit at dinner? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

10. Is your child willing to try a new kind of vegetable? (Circle one.)

1. No

2. Maybe

3. Yes

11. How many days during the past week did you give your child a vegetable for a snack? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

12. How many days during the past week did you give your child a vegetable at dinner? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Milk

13. Did your child drink milk or use milk on his/her cereal at home during the past week? (Circle one.)

1. No [Go to Question 16]

2. Yes

14. What kind of milk did your child most often drink or use on his/her cereal at home during the past week? (Circle one.)

1. Whole milk

2. 2% milk, also called reduced-fat milk

3. 1% milk, also called low-fat milk

4. Skim milk, also called fat-free milk

5. Other type of milk, such as soy, almond, or rice milk

15. How many days during the past week did you give your child milk to drink at dinner? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

16. Which one of these statements best describes how you feel about the milk you give your child? (Circle one.)

1. I believe that whole milk is healthier for my child than 1% or skim milk.

2. I believe that 1% or skim milk is healthier for my child than whole milk.

3. I believe that whole milk and 1% or skim milk are equally healthy for my child.

Questions on Shopping and Eating Habits

17. How strongly do you agree or disagree with each of these statements? (Circle one for each statement.)

    It is easy to buy fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree
    There is a large selection of fresh fruits or vegetables where I live.	Strongly agree	Agree	Disagree	Strongly disagree
    I do not usually buy fresh fruits or vegetables because they spoil quickly.	Strongly agree	Agree	Disagree	Strongly disagree
    I can afford fruits or vegetables in the store where I shop for most of my food.	Strongly agree	Agree	Disagree	Strongly disagree
    I can encourage my child to try new fruits or vegetables.	Strongly agree	Agree	Disagree	Strongly disagree
    I usually drink 1% or skim milk.	Strongly agree	Agree	Disagree	Strongly disagree

18. During the past month, how often did your child ask you to buy a certain type of fruit? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

19. During the past month, how often did your child ask you to buy a certain type of vegetable? (Circle one.)

1. Never

2. Seldom

3. Sometimes

4. Often

5. Always

20. How many days during the past week did you and your child sit down to eat dinner as a family? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

21. How many days during the past week did your child eat dinner with the TV on? (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

22. How many days during the past week did you eat fruit for a snack? Do NOT include fruit juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

23. How many days during the past week did you eat vegetables for a snack? Do NOT include white potatoes, French fries, or vegetable juice. (Circle one.)

1. None

2. 1 to 2 days

3. 3 to 4 days

4. 5 to 6 days

5. Every day

Questions on Nutrition Education Materials Your Child Got at School

24. Did the child participating in the “What Does Your Child Eat Study” change schools during the school year?

1. No [Go to Question 26]

2. Yes

25. What is the name of your child’s new school and the county in which it is located?

School name:

County:

26. Your child’s teacher sent home a sheet called “BE A MILK SUPERSTAR!!” The sheet asked you and your child to track each time a family member had milk, cheese, or yogurt. Did you or someone else in your household do the sheet with your child? (Circle one.)

1. Did not get sheet

2. No

3. Yes

27. During the school year, your child’s teacher sent home bingo cards once a month with pictures of fruits and vegetables and children being active. How many months did your child eat the fruits or vegetables or do the activities on the card to try to get bingo? (Circle one.)

1. Did not get bingo cards [Go to Question 29]

2. None

3. 1 to 2

4. 3 to 4

5. 5 to 6

6. 7 to 8

28. The back of the bingo cards included recipes and other information on healthy eating and exercise. How many months did you or someone else in your household make one of the recipes with your child? (Circle one.)

1. None

2. 1 to 2

3. 3 to 4

4. 5 to 6

5. 7 to 8

29. Your child’s teacher sent home family newsletters with tips on healthy eating and recipes. Did you or someone else in your household read the family newsletters? (Circle one.)

1. Did not get family newsletters [Go to Question 32]

2. No [Go to Question 32]

3. Yes, some of them

4. Yes, all or most of them

30. How easy was it to understand the family newsletters and other materials sent home by your child’s teacher? (Circle one.)

1 Not at all easy

2. Not very easy

3. Somewhat easy

4. Easy

5. Very easy

31. How strongly do you agree or disagree with this statement? “I used the information from the family newsletters and other materials to help my child eat healthier foods.” (Circle one.)

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

32. Your child’s school had events on healthy eating and exercise called Family Night Out. How many Family Night Out events did you or someone else in your household go to? (Circle one.)

1. None [Go to Question 34]

2. One

3. Two

4. More than two

33. How strongly do you agree or disagree with this statement? “I used the information I learned from the Family Night Out events to help my child eat healthier foods.” (Circle one.) [Go to Question 35 after answering this question]

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

34. Why didn’t you go to any of the Family Night Out events? (Circle all that apply.)

1. The events were not offered at my child’s school

2. Did not know about the events

3. The events were offered at times that did not work for me

4. Did not think the events would be useful

5. Do not like to go to events like this

6. Other reason (Describe):

35. Please share any comments about the Family Night Out events, family newsletters, bingo cards, and other materials.

36. Have you seen, read, or heard about any of these campaigns on healthy eating? (Circle Yes or No for each campaign.)

    “Pick a Better Snack”	Yes	No
    “1% or Less, YES!”	Yes	No
    “Mr. Juicebar”	Yes	No
    “Be Strong”	Yes	No

37. Where did you see, read, or hear about “Pick a Better Snack?” (Circle all that apply.)

1. Did not see, read, or hear about this campaign

2. Radio

3. TV

4. Billboards, signs on buses, or at bus stops

5. Newspaper

6. Poster, brochure, or other materials that I saw or got at the grocery store

7. Poster, brochure, or other materials that I saw or got at my child’s school

8. Poster, brochure, or other materials that I saw or got at food assistance programs, such as food pantries, WIC clinics, or Department of Human Services (DHS)

9. Other (Describe):

38. Where did you see, read, or hear about 1% or Less, YES!?” (Circle all that apply.)

1. Did not see, read, or hear about this campaign

2. Radio

3. TV

4. Billboards, signs on buses, or at bus stops

5. Newspaper

6. Poster, brochure, or other materials that I saw or got at the grocery store

7. Poster, brochure, or other materials that I saw or got at my child’s school

8. Poster, brochure, or other materials that I saw or got at food assistance programs, such as food pantries, WIC clinics, or Department of Human Services (DHS)

9. Other (Describe):

39. Where did you see, read, or hear about “Be Strong?” (Circle all that apply.)

1. Did not see, read, or hear about this campaign

2. Radio

3. TV

4. Billboards, signs on buses, or at bus stops

5. Newspaper

6. Poster, brochure, or other materials that I saw or got at the grocery store

7. Poster, brochure, or other materials that I saw or got at my child’s school

8. Poster, brochure, or other materials that I saw or got at food assistance programs, such as food pantries, WIC clinics, or Department of Human Services (DHS)

9. Other (Describe):

Thank you for completing our survey.
Please return the survey to RTI in the enclosed envelope.

If you have misplaced the envelope, call 1-866-800-9176
for a replacement or mail the survey to
RTI INTERNATIONAL
ATTN: Data Capture (0212343.001.008.002)
PO Box 12194
Research Triangle Park, NC 27709-9779

1ote: Graphics courtesy of Dr. Marilyn Townsend and Kathryn Sylva, University of California, Davis.