Survey - Word

C1. National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living

Form Approved
OMB No: 0920-xxxx

Expiration Date: xx/xx/xxxx

National Survey of Community-Based Policy and
Environmental Supports for Healthy Eating and Active Living

Sponsored by:

Department of Health and Human Services

Centers for Disease Control and Prevention

Division of Nutrition, Physical Activity, and Obesity

National Center for Chronic Disease Prevention and Health Promotion

For questions about the survey, please contact the survey hotline, 1-800-XXX-XXXX or

Erika Gordon, Project Director,

ICF International

11785 Beltsville Drive, Suite 300
Calverton, MD 20705

IF YOU CHOOSE TO COMPLETE THE PAPER QUESTIONNAIRE, PLEASE ENTER YOUR STUDY ID AND THEN SEND COMPLETED SURVEY TO ICF INTERNATIONAL.

Study ID______________ Name of Municipality/State: _____________________________

Burden Statement:

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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D74, Atlanta, GA 30333; ATTN: PRA 0920-xxxx. Do not return the completed form to this address.

If you choose to complete the paper questionnaire, please enter your study ID and then send completed survey to ICF.

Study ID______________ Name of Municipality/State: ______________________________

If you choose to complete the paper questionnaire, please enter your study ID and then send completed survey to ICF.

Study ID______________ Name of Municipality/State: ______________________________

If you choose to complete the paper questionnaire, please enter your study ID and then send completed survey to ICF.

Study ID______________ Name of Municipality/State: ______________________________

If you choose to complete the paper questionnaire, please enter your study ID and then send completed survey to ICF.

Study ID______________ Name of Municipality/State: ______________________________

National Survey of Community-Based Policy and
Environmental Supports for Healthy Eating and Active Living

Consent to Participate

You have been invited to take part in the National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living (CBS HEAL Survey), a survey sponsored by the U.S. Centers for Disease Control and Prevention (CDC). The national study seeks to gather information on the existence of certain policies, standards, and practices enacted or implemented by local governments that promote more healthful eating and physical activity for residents.

You were identified as the person best able to address questions about the policies enacted by your local government. Your participation in this study will involve responding to a Web-based questionnaire that will take approximately 30 minutes to complete.

Your participation is voluntary and you may stop participating at any time. You have the right to refuse to answer any question. Your participation will be treated in a secure manner and will not be disclosed, unless required by law. The information you give us will be combined with the responses of participants in other communities in a summary report. CDC will provide your local government with a brief summary report that compares the findings from your community with those of other communities in the study. There are no risks or benefits to you for participating.

If you have any questions about the study, please call Dr. Deborah Galuska of CDC at 770-488-6017 or Dr. Erika Gordon of ICF International at 1-800-XXX-XXXX. The Institutional Review Board at ICF International has determined this study to be exempt from the human subjects review process. If you have any questions about your rights as a study participant, you can call XXXXXX at CDC at 1-800- XXX-XXXX.

You may access the questionnaire at http://www.CBSSURVEYWEBSITE HERE.com to participate. Please refer to the materials enclosed with this form to obtain further information on how to complete this questionnaire, as well as your token ID to access the survey.

Thank you.

National Survey of Community-Based Policy and
Environmental Supports for Healthy Eating and Active Living

Survey Introduction and Special Instructions:

Healthy eating and active living are important behaviors for the prevention of obesity and other chronic diseases such as heart disease, diabetes, and cancer. The ability to make healthy choices is influenced by one’s surroundings—where one lives, works, shops, and plays. Policies, standards, and practices at local levels can influence these surroundings to support healthy eating and active living. To better understand these policies, standards, and practices the U.S. Centers for Disease Control and Prevention (CDC) is conducting this survey of local governments across the Nation.

This survey asks about select policies, standards, and practices of the local government in your community. In this survey, local government generally refers to a municipality, town, or township but not to a county or State. For the purposes of this survey, policies and standards are any written codes or standards, including regulations, ordinances, organizational policy, resolutions, and formal rules.

On average, it will take you 30 minutes to complete the survey. You may need to consult with another person to provide the most accurate and complete information on your local government’s policies and standards concerning recreational spaces, nutritional standards, or on support for maternity leave. For example, a tax office or procurement department representative, a parks and recreation department representative, or a human resources representative may be consulted for the survey.

Completing the survey is voluntary. CDC may choose to link the data collected in this survey with other U.S. Census data to gain a better understanding of the prevalence of certain types of policies, standards, and practices within communities. While no specific respondent to the questionnaire will ever be identified, this linking of data may identify communities.

SECTION 1. COMMUNITYWIDE PLANNING EFFORTS FOR HEALTHY EATING AND ACTIVE LIVING

These questions ask about communitywide planning documents that local governments may have created or adopted that promote healthy eating and active living. These may include Comprehensive/General Plans, or other plans such as a transportation plan, a parks and recreation plan, or a bicycle and pedestrian plan.

1. Does your local government have a Comprehensive/General Plan?

1. Yes

2. No (GO TO QUESTION 2)

3. Don’t know (GO TO QUESTION 2)

1A. Was the development of your Comprehensive/General Plan mandated by the State?

1. Yes

2. No

3. Don’t know

2. Does your local government have any of the following types of master plans, including standalone plans that are not a part of the Comprehensive/General Plan such as …

1. A land use plan (for new development and growth management)?

(a). Yes

(b). No

(c). Don’t know

2. A transportation plan?

(a). Yes

(b). No

(c). Don’t know

3. A parks and recreation plan?

(a). Yes

(b). No

(c). Don’t know

4. A bicycle or pedestrian plan?

(a). Yes

(b). No

(c). Don’t know

3. Does your local government have any of the following objectives included in your plan(s)? These objectives should be written in the plan. However, they do not have to have been implemented yet.

1. Implementing a Complete Streets policy (as defined by the National Complete Streets Coalition) for new and retrofit projects?

Help Statement: A Complete Streets policy, as defined by the National Complete Streets Coalition, is a policy ensuring that transportation planners and engineers consider the needs of all users during the design of major road projects, including bicyclists, pedestrians of all ages and abilities, public transit vehicles and riders, and motorists.

(a). Yes

(b). No

(c). Don’t know

2. Developing regulations that promote street connectivity?

(a). Yes

(b). No

(c). Don’t know

3. Establishing new parks, green spaces, or recreational walking and bicycling paths?

(a). Yes

(b). No

(c). Don’t know

4. Encouraging mixed-use development that combines residential land use with one or more commercial, institutional, or other public land uses?

(a). Yes

(b). No

(c). Don’t know

5. Supporting farmers markets or community gardens?

(a). Yes

(b). No

(c). Don’t know

6. Preserving land for agricultural uses?

(a). Yes

(b). No

(c). Don’t know

G. Providing free drinking water in outdoor publically accessible places such as parks?

a). Yes

(b). No

(c). Don’t know

SECTION 2. THE BUILT ENVIRONMENT AND POLICIES THAT SUPPORT PHYSICAL ACTIVITY

The next questions ask about policies or standards that support the physical activity of your community’s residents, even if the policy or standard was passed by another level of government (such as a regional transportation planning authority). You may find it helpful to consult with a representative in either the parks and recreation department or transportation department if you cannot answer a question.

4. Does your local government have design standards, guidelines, or policies that require …

1. Installation of dedicated bicycle infrastructure for roadway expansion projects or when retrofitting streets?

(a). Yes

(b). No

(c). Don’t know

2. Developer-dedicated right-of-way to the local jurisdiction for development of bicycle infrastructure?

(a). Yes

(b). No

(c). Don’t know

3. Traffic-calming features (for example, speed bumps, reduced speed zones, or signal modifications)that increase roadway safety in areas with high pedestrian and bicycle volume (not including school zones)?

(a). Yes

(b). No

(c). Don’t know

5. Does your local government have a formal Complete Streets policy, as defined by the National Complete Streets Coalition, for designing and operating streets with safe access for all users?

Help Statement: A Complete Streets policy, as defined by the National Complete Streets Coalition, is a policy ensuring that transportation planners and engineers consider the needs of all users during the design of major road projects, including bicyclists, pedestrians of all ages and abilities, public transit vehicles and riders, and motorists.

(a). Yes

(b). No

(c). Don’t know

5. Does your local government have a written requirement or official objective to install bicycle racks at public facilities, such as public parks, government buildings, or transit stations?

(a). Yes

(b). No

(c). Don’t know

5. Does your local government include any of the following features in policies for development, including zoning codes and design/development guidelines?

1. Require short- to medium pedestrian-scale block sizes (for example, less than 600 feet x 600 feet)?

(a). Yes

(b). No

(c). Don’t know

2. Require continuous sidewalk coverage?

(a). Yes

(b). No

(c). Don’t know

3. Require minimum sidewalk widths of 5 feet?

(a). Yes

(b). No

(c). Don’t know

4. Require that buildings relate to the street at a pedestrian scale (for example, require entrances that face the street, windows or other architectural features that face the street, or reduced front setbacks)?

(a). Yes

(b). No

(c). Don’t know

5. Require pedestrian amenities such as trees or furniture along the street?

(a). Yes

(b). No

(c). Don’t know

6. Require parking standards that encourage walking and bicycling (for example, parking maximums or rear and side parking requirements)?

(a). Yes

(b). No

(c). Don’t know

7. Require or provide incentives for placing drinking fountains or other dispensers in outdoor publically accessible places?

(a). Yes

(b). No

(c). Don’t know

H. Have a municipal plumbing or building code that contains a different drinking fountain requirement than the drinking fountain requirements contained in the statewide plumbing code?

(a). Yes

(b). No

(c). Don’t know

9. Allow mixed land uses (for example, zoning that combines residential land use with one or more commercial, institutional, or public land uses)?

(a). Yes

(b). No

(c). Don’t know

The next questions ask about parks and outdoor recreation areas and policies supporting recreation.

5. Does your local government have policies or budget provisions related to parks or outdoor recreation areas, such as …

1. Lighting in parks or outdoor recreation areas?

(a). Yes

(b). No

(c). Don’t know

B. Patrols by police or security in parks or outdoor recreation areas?

(a). Yes

(b). No

(c). Don’t know

C. Maintenance of green space and equipment?

(a). Yes

(b). No

(c). Don’t know

D. Prohibition of unleashed or unrestrained dogs in parks and outdoor recreation areas?

(a). Yes

(b). No

(c). Don’t know

E. Prohibition of cars idling in parks or outdoor recreation areas?

(a). Yes

(b). No

(c). Don’t know

F. Provision of free drinking water in parks or outdoor recreation areas?

(a). Yes

(b). No

(c). Don’t know

9. Has your local government adopted a joint or shared use agreement or a memorandum of understanding with any school that allows the public to use school recreational facilities (for example, gymnasiums, athletic fields, or playgrounds) during nonschool hours?

1. Yes

2. No (GO TO QUESTION 10)

1. Our municipality does not have schools in our jurisdiction (GO TO QUESTION 10)

2. Don’t know (GO TO QUESTION 10)

9A. Who is your joint use or shared use agreement with?

1. Local school district or board

2. Individual school

3. Other

4. Don’t know

9B. What school recreational facilities are covered by the joint or shared use agreement or a memorandum of understanding?

1. Outdoor facilities only

2. Indoor facilities only

3. Outdoor and indoor facilities

4. Don’t know

10. Does your local government have a planning and/or zoning commission?

1. Yes

2. No (GO TO QUESTION 11)

3. Don’t know (GO TO QUESTION 11)

10A. Is there a designated health/public health representative on the planning and/or zoning commission?

1. Yes

2. No

3. Don’t know

11. Does your local government have a pedestrian, bicycle, or alternative transportation advisory committee?

1. Yes

2. No (GO TO SECTION 3)

3. Don’t know (GO TO SECTION 3)

11A. Is there a designated health/public health representative on the bicycle and/or pedestrian advisory committee?

1. Yes

2. No

3. Don’t know

SECTION 3. POLICIES AND PRACTICES THAT SUPPORT ACCESS TO HEALTHY FOOD AND HEALTHY EATING

The next questions are about policies that may affect access to healthy food options in your community, even if the policy or standard was passed by another level of government. If you feel you cannot provide the best answer, you may find it helpful to consult with the following types of representatives within your local government: a public health official, a representative in the tax assessor’s office, or a purchasing or procurement representative.

12. Does your local government have written nutrition standards for foods sold or served in local government buildings or worksites, including meals, a la carte items, or vending machines? Examples of nutrition standards include provisions for reduced sodium content or for inclusion of fresh fruit and vegetable selections. Do not include public school district or school-level policies in your response.

1. Yes

2. No (GO TO QUESTION 14)

3. Don’t know (GO TO QUESTION 14)

13. Do these standards require …

1. Offering vegetables and fruits, including fresh, dried, or canned items?

1. Yes

2. No

3. Don’t know 

2. Offering whole grain options?

1. Yes

2. No

3. Don’t know

3. Offering low-fat milk, yogurt, or cheese?

1. Yes

2. No

3. Don’t know

4. Offering foods with less sodium?

1. Yes

2. No

3. Don’t know

4. Only offering foods with no trans-fat?

1. Yes

2. No

3. Don’t know

5. Labeling foods with calories per serving?

1. Yes

2. No

3. Don’t know

6. Offering lower-calorie beverage choices (for example, unsweetened tea, diet soda)?

1. Yes

2. No

3. Don’t know

7. Offering free drinking water?

1. Yes

2. No

3. Don’t know

13B. Do these written nutrition standards for foods sold or served in local government buildings or worksites, including meals, a la carte items, or vending machines apply to local government facilities that serve foods and beverages to local government employees?

(a). Yes

(b). No

(c). Don’t know

13C. Do these written nutrition standards for foods sold or served in local government buildings or worksites, including meals, a la carte items, or vending machines, apply to local government facilities that serve foods and beverages to the general public?

(a). Yes

(b). No

(c). Don’t know

13D. Do these written nutrition standards for foods sold or served in local government buildings or worksites, including meals, a la carte items, or vending machines, apply to local government facilities that serve foods and beverages to institutionalized persons (for example, prisons, centers for the developmentally disabled)?

(a). Yes

(b). No

(c). Don’t know

14. Does your local government have pricing incentives to promote the purchase of healthier foods and beverages sold in local government buildings, including cafeterias or vending machines? An example of this is intentionally pricing more healthful items to be less expensive. Do not include public school district or school-level policies in your response.

(a). Yes

(b). No

(c). Don’t know

The next questions ask you about policies that support increasing access to healthful foods. Supermarkets and full-service grocery stores typically stock a higher proportion of healthier foods than smaller stores, including convenience and corner stores. Supermarkets and full-service grocery stores sell a general line of foods, including canned and frozen foods; fresh fruits and vegetables; and fresh and prepared meats, fish, and poultry.

15. Does your local government currently use any of the following approaches to encourage supermarkets and other full-service grocery stores to open stores?

1. Tax incentives (for example, tax abatement, tax credit, or property tax exemption)?

(a). Yes

(b). No

(c). Don’t know

2. Grant or loan programs?

(a). Yes

(b). No

(c). Don’t know

3. Zoning or ordinance requirement fee waivers or streamlined processes for obtaining health and food safety permits and licenses?

(a). Yes

(b). No

(c). Don’t know

4. Programs to link store openings to broader neighborhood revitalization projects (for example, improvements to lighting, signage, safety, or walkability in the surrounding commercial corridor)?

(a). Yes

(b). No

(c). Don’t know

5. Does your local government use other incentive programs?

1. Yes

2. No

3. Don’t know

15A. Do any of these policies or programs used by your community to encourage supermarkets and other full-service grocery stores to open stores explicitly prioritize low-income or economically depressed areas?

1. Yes

2. No

3. Our community does not have any low-income or economically depressed areas

4. Don’t know

In addition to supermarkets and full-service grocery stores, food can be sold in smaller venues such as convenience or corner stores. Some local governments use incentives, training, or grants to help convenience or corner stores sell healthier foods.

16. Does your local government provide …

1. Grant or low-interest loan programs to purchase/upgrade store equipment or furnishings to properly store and sell healthful foods and beverages (for example, fresh produce, low-fat milk, or whole grains)?

(a). Yes

(b). No

(c). Don’t know

2. Technical assistance or training programs that increase the ability to sell healthier foods (for example, marketing, promotion materials, and/or product placement)?

(a). Yes

(b). No

(c). Don’t know

3. Programs to link stores to broader neighborhood revitalization projects (for example, improvements to lighting, signage, safety, or walkability in the surrounding commercial corridor)?

(a). Yes

(b). No

(c). Don’t know

4. Does your local government provide other types of incentive programs that help convenience or corner stores sell healthier foods?

(a). Yes

(b). No

(c). Don’t know

16A. Do any of these policies or programs used to help convenience or corner stores sell healthier foods explicitly prioritize low-income or economically depressed areas?

1. Yes

2. No

3. Our community does not have low-income or economically depressed areas

4. Don’t know

Some residents may not have easy access to supermarkets or full-service grocery stores because they do not have access to a car or public transportation or cannot easily walk to them. These next questions ask about policies and standards that your community may use to support access to supermarkets or full-service grocery stores.

17. Does your local government have a policy that supports dedicated transportation (for example, community vans or shuttle buses) to supermarkets, other full-service grocery stores, or farmers markets for these residents? Do not include public transportation options in your response.

1. Yes

2. No

3. Don’t know

17. Does your local government consider accessibility to supermarkets or other full-service grocery stores in their assessment of public transportation routes?

1. Yes

2. No

3. Our community does not have public transportation

4. Don’t know

17. Does your local government have any policies related to farmers markets, farm stands, or green/produce carts that …

1. Allow the sale of fresh produce on city property?

(a). Yes

(b). No

(c). Don’t know

2. Streamline processes for obtaining health and food safety permits and licenses?

(a). Yes

(b). No

(c). Don’t know

3. Extend waivers of required business permits or retail licensing fees or taxes?

(a). Yes

(b). No

(c). Don’t know

4. Provide funds or in-kind services for personnel, signage, or advertising?

(a). Yes

(b). No

(c). Don’t know

5. Encourage opening in areas lacking supermarkets or full-service grocery stores?

(a). Yes

(b). No

(c). Don’t know

17. Does your local government provide funding for Electronic Benefits Transfer (EBT) machines or provide technical assistance on how to obtain or use EBT machines at local farmers markets, farm stands, or green/produce carts?

Help Statement: Electronic Benefit Transfer (EBT) is an electronic system that allows the government to provide assistance benefits (such as the Supplemental Nutrition Assistance Program [SNAP] or the Temporary Assistance for Needy Families [TANF]) via a plastic debit card to eligible constituents.

1. Yes

2. No

3. Our community does not have a farmers market, farm stand, or green/produce cart

4. Don’t know

17. Does your jurisdiction have a local or regional food policy council, food security coalition, or similar entity?

Help Statement: A food policy council is a council that brings together stakeholders from diverse food-related sectors in a specific geographical area to examine how the food system is operating in that area and to develop recommendations for improvement.

(a). Yes

(b). No (GO TO QUESTION 22)

(c). Don’t know (GO TO QUESTION 22)

21A. Is a local government employee or elected official a member of the food policy council, food security coalition, or similar entity?

1. Yes

2. No

(c). Don’t know

21B. Is there a designated health/public health representative on the food policy council, food security coalition, or similar entity?

1. Yes

2. No

(c). Don’t know

These next questions ask about policies for employee breast-feeding. Federal law requires employers to provide breast-feeding employees with break time and a private space other than a bathroom to pump breast milk. The law applies only to women who work for hourly wages.

22. Is there a policy that allows ALL breast-feeding employees in the local government break time and space to pump breast milk?

(a). Yes (GO TO 22A)

(b). No

(c). Don’t know

22A.  Is this a local or State policy?

(a). Local

(b). State

(c). Don’t know

23. Does your local government provide paid maternity leave for its employees?

Help Statement: Paid maternity leave is paid leave that does not use already accrued leave such as vacation or sick leave. It also does not include leave allowed under the Family Medical Leave Act (FMLA). A human resources department representative may be helpful in answering this question.

(a). Yes (GO TO 23A)

(b). No (GO TO SUBMIT SCREEN)

(c). Don’t know (GO TO SUBMIT SCREEN)

23A. How long is this maternity leave?

1. Less than 4 weeks

2. 4–7 weeks

3. 8–12 weeks

4. 3 months or more

5. Don’t know

THANK YOU FOR COMPLETING THIS SURVEY