0917-0036 Community Nutrition Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Community Nutrition – Food Demonstration

Date ________________ Topic: ______________________________________
Age: __ 5 years and younger __ 6 – 17 years __ 18 – 34 years __ 35 – 64 years __ 65 years and older

Gender: __ Male __ Female

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

1. I would recommend Office of Community Nutrition to my family and friends 1 2 3 4 5

2. Usually my health is good 1 2 3 4 5

3. I am sure I can take care of my own health (T’áá hwó ájít’éego) 1 2 3 4 5

4. The staff was organized and had all materials, utensils and samples prepared ahead of time 1 2 3 4 5

5. I like that I can watch the Food Demo on the television in the lobby while I wait 1 2 3 4 5

6. I learned something new about food or nutrition by watching todays food demonstration 1 2 3 4 5

7. I am likely to prepare this recipe within the next 90 days 1 2 3 4 5

8. I liked the taste of this recipe as it was served today 1 2 3 4 5

9. This recipe has nutrients that I and/or my family needs 1 2 3 4 5

What comments or suggestions do you have to improve our services? _______________________________________________________________________________________

How will you use the information presented? _______________________________________________________________________________________

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COMMUNITY NUTRITION STAFF ONLY

Presenter’s Name: ­­­­­­­­­­­­­­_____________________________ Facilitator’s Name: _________________________

__ Healthy Weight __ Food Accessibility __ Breastfeeding

Rev. 01/15/2014

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 0917-0036.  The time required to complete this information collection is estimated to average 3 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 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.