17.7 Survey

Attach B12. LOI2-QUEX-14 Child Food Questionnaire

OMB #: 0925-0593
Expiration Date: 08/31/2014

BAR CODE LABEL
OR SUBJECT ID HERE

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National Children’s Study

Child Food Questionnaire

2-5 years

Public reporting burden for this collection of information is estimated to average 30 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0593). Do not return the completed form to this address.

Please complete this questionnaire at the end of the month and bring it with you to the site visit.

LABEL FOR CLINICAL CENTER RETURN ADDRESS

General Instructions
This questionnaire is about your child __________________. When we refer to “your child,”
please respond with this child in mind.
This questionnaire asks you about the foods your child has eaten in the past month.
Answer each question as best you can. Estimate if you are not sure. A guess is better than
leaving a blank.
Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Do not fold, staple, or tear
the pages.
Put an X in the box next to your answer.
If you make any changes, cross out the incorrect answer and put an X in the box next to the
correct answer. Also draw a circle around the correct answer.

BEFORE YOU BEGIN, PLEASE FILL IN TODAY’S DATE:

__ __/__ __/__ __
Month Day

CFQ - 2

Year

A.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

FFrruuiittss

Never

Less than
1 time
per week

1 time
per week

1. Orange
2. Grapefruit
3. Banana
4. Apple
5. Applesauce
6. Grapes
7. Peach or plum
8. Strawberries or other
berries
9. Cantaloupe
10. Watermelon
11. Pears
12. Raisins or prunes

CFQ - 3

2–4 times
per week

Nearly
every day or
2 or more
every day times per day

B.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Vegetables Never

Less than
1 time
per week

1 time
per week

1. Corn
2. Peas
3. Tomatoes
4. Peppers (all kinds)
5. Carrots
6. Broccoli
7. Green beans
8. Spinach
9. Squash
(orange or winter)
10. French fries, fried potatoes
11. Potatoes (baked, boiled or
mashed)
12. Onion
13. Sweet potatoes or yams
14. Cabbage, coleslaw, or
cauliflower
15. Cucumbers
16. Lettuce salad
17. Mixed vegetables
18. Baked beans or chili beans
19. Other dried beans, dried
peas or lima beans

CFQ - 4

2–4 times
per week

Nearly
every day or 2 or more
every day times per day

C.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Meat,
fish, and
other main dishes

Never

Less than
1 time
per week

1 time
per week

1. Pizza
2. Macaroni and cheese
3. Peanut butter
4. Hamburger, meatballs, or
meatloaf
5. Beef—steak or roast
6. Pork—chops, roast, or ribs
7. Ham—baked or steak
8. Cold cuts
(bologna, salami, ham)
9. Sausage
10. Bacon
11. Hot dogs
12. Fried chicken, chicken
nuggets
13. Other chicken or turkey
14. Canned tuna
15. Fried fish, fish sticks
16. Other fish
17. Tofu or soy beans
18. Vegetable soup
19. Other soup

CFQ - 5

2–4 times
per week

Nearly
2 or more
every day or
every day
times per day

D.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Starches
& grains

Never

Less than
1 time
1 time
per week per week

1. Pasta
2. White rice
3. Brown Rice
4. White bread
(slice, roll, or pita)
5. Dark bread
(slice, roll, or pita)
6. Cornbread or tortilla
7. Oatmeal
8. Cereal (cold)
9. Donut, fried dough
10. Sweet roll or muffin
11. Pancake, waffle, or
French toast
12. English muffin or
bagel
13. Biscuit

CFQ - 6

2–4 times
per week

Nearly
2 or more 5 or more
every day
times
times
or every day per day
per day

E.

Please check the box that best represents how often your child drank each of the beverages
listed, on average, in the past month.

Drinks

Less than
Nearly
2 or more 5 or more
1 time
1 time 2–4 times every day or
times
times
Never per week per week per week every day
per day
per day

1. Milk, including chocolate
milk
2. Hot chocolate
3. Apple juice
4. Grape juice
5. Orange juice
6. Pineapple juice
7. Other 100% juice
8. Fruit drinks
(Hi-C, Kool-Aid, lemonade)
9. Soda (not sugar-free)
10. Soda (sugar-free)
11. Water

12.

What kind of milk does your child usually drink?
Breast milk, breast fed...................

1% milk ................................................

Breast milk, expressed ..................

Skim milk .............................................

Formula made from cow’s milk .....

Soy milk ...............................................

Formula made from soy milk .........

Other....................................................

Whole milk .....................................

My child does not drink milk ................

2% milk ..........................................
13.

What kind of water does your child usually drink?
Tap water, not filtered....................
Tap water, filtered..........................
Bottled water .................................

CFQ - 7

F.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Other dairy
& eggs
Never
1.

Cheese, plain or in
sandwiches

2.

Cream cheese

3.

Cottage cheese

4.

Yogurt

5.

Ice cream

6.

Pudding

7.

Whole eggs

G.

Less than
1 time
per week

1 time
per week

2–4 times
per week

Nearly
2 or more
every day or
every day
times per day

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Oils and
spreads

Never

Less than
1 time
1 time
per week per week

1. Butter (not margarine)
2. Margarine (tub)
3. Margarine (stick)
4. Mayonnaise
5. Salad dressing

CFQ - 8

2–4 times
per week

Nearly
2 or more 5 or more
every day or
times
times
every day
per day
per day

H.

Please check the box that best represents how often your child ate each of the foods listed, on
average, in the past month.

Snacks and
sweets

Never

Less than
1 time
1 time
per week per week

Nearly
2 or more 5 or more
2–4 times every day or
times
times
per week
every day
per day
per day

1. Chips
(potato, corn or others)
2. Nuts
3. Crackers
4. Jell-O
5. Cookies or brownies
6. Cake or cupcakes
7. Pie
8. Chocolate candy
9. Other candy

I.

Are there any other foods not mentioned above that your child eats at least once per week? Please
write in the name of the food and check the box that best represents how often your child ate each
food, on average, in the past month.

Other foods
your child eats
once per week

1 time
per week

Nearly
2–4 times every day or 2 or more
5 or more
per week
every day times per day times per day

1. __________________________
2. __________________________
3. __________________________
4. __________________________
5. __________________________
6. __________________________
7. __________________________

CFQ - 9

J.

In the past month, how often does your child eat fast foods away from home or as take out
(French fries, egg rolls, fried chicken, shrimp, clams, etc.)?
Less than once per week ..............
1 time per week .............................
2 to 4 times per week ....................
Nearly every day or every day ......

K.

In the past month, did you always, usually, sometimes, or seldom:
Always

Usually

Sometimes

Seldom

1. Wash your hands before preparing food for your
family?
2. Wash the cutting board or counter before
preparing food on it for your family?
3. Wash or rinse fresh fruits and vegetables 20
seconds and drain 2 minutes before preparing
them for your family?

L.

In the past month, did your child eat any of the following foods that contain raw eggs?
Yes

1. Raw, homemade cookie or cake batter?
2. Homemade frosting with raw egg?
3. Caesar salad with raw egg?
4. Chocolate mousse with raw egg?
5. Homemade eggnog?
6. Homemade ice cream with raw egg?
7. Shakes with raw egg?

CFQ - 10

No

Don’t know

M. Where does your child eat, including breakfast, lunch, dinner, and snacks?
For each of these places, tell me if she eats in these places usually, sometimes,
or never.
Usually
Sometimes
1. Kitchen table or counter
2. High chair
3. Dining room table
4. Living room on a table or coffee table
5. On the carpet or floor anywhere in the house
6. Bedroom on a table or dresser
7. Garage
8. On a table or bench outside the house
9. Anywhere else he or she chooses

N. Which of the following supplements was your child given at least 3 days a week
during the past month? [MARK ALL THAT APPLY.]
Fluoride .....................................................................
Iron ............................................................................
Vitamin D ...................................................................
Multi-vitamins ............................................................
Other vitamins or supplements:
Specify ________________________________ .....
None ..........................................................................

O.

Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS PILLS.]
Drops .........................................................................
Pills ............................................................................

CFQ - 11

Never

Thank you very much for completing this questionnaire!
All of your answers are very important.

Please help us by looking at each page again to make sure that you:
Did not skip any pages and
Crossed out the wrong answer and circled the right answer if you made any changes.

Thank you for continuing to be part of
the National Children’s Study.

CFQ - 12