Individuals and Households Respondents
Study of Nutrition and Activity in Child Care Settings II (SNACS-II)
F21_Food and Physical Activity Experiences Survey
Individuals and Households Respondents
OMB: 0584-0669
F21. Food and Physical Activity Experiences Survey
This page has been left blank for double-sided copying.
OMB
Number: 0584-XXXX Expiration
Date: XX/XX/20XX
Study of Nutrition and Activity in Child Care Settings II (SNACS-II)
Food and Physical Activity Experiences Survey
The
Food and Nutrition Service (FNS) is collecting this information to
understand the nutritional quality of CACFP meals and snacks, the
cost to produce them, and dietary intakes and activity levels of
CACFP participants. This is a voluntary collection and FNS will use
the information to examine CACFP operations. The collection does
request personally identifiable information under the Privacy Act of
1974. Responses will be kept private to the extent provided by law
and FNS regulations. According to the Paperwork Reduction Act of
1995, an agency may not conduct or sponsor, and a person is not
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 0584-xxxx. The time required to
complete this information collection is estimated to average 0.167
hours (10 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. 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 Service, Office of Policy
Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN:
PRA (0584-xxxx). Do not return the completed form to this address.
Study of Nutrition and Activity in Child Care Settings II
Assent Form
What is SNACS-II?
This study is for the U.S. Department of Agriculture (USDA). USDA is the part of the federal government that is responsible for the meals and snacks in your afterschool program. Part of the study will look at the experiences of youth like you who attend these programs. The study is being conducted by two companies called Mathematica and Westat.
What is expected of me?
The data collector visiting your afterschool program will ask you to complete this paper survey. The survey has questions about your participation in your afterschool program, the types of activities you do, and your food situation at home. If you return the completed survey to the data collector, they will give you a small gift for helping with the study.
Do I have to participate in the study?
No. You can decide if you want to be in the study or not. Your parent or guardian gave permission for you be in the study, but you can still choose not to participate. Your decision will not affect your participation in this program in any way. You may also change your mind at any time, and you can choose to skip questions in the survey.
Will anyone know I am in the study?
No. Your name will not be part of the study. Your answers will be kept private. All information gathered for the study is private under the Privacy Act to the extent allowed by law. The data collector is not allowed to share your personal information with anyone except other people working on this study.
Are there any risks or benefits to being in the study?
You will not benefit directly from being in the study, but you will help USDA and afterschool programs like this one understand the youth they serve. Although there is a very small chance someone could see your answers, the study team has taken many steps to reduce this risk. For example, we did not put your name on this survey.
Who can I talk to about the study?
If you or your parent or guardian have any questions about the study, please call the study team at [study number] (toll-free). If you or your parent or guardian have any questions about your rights as a research participant, please call [IRB number].
If you decide to participate, please fill out this survey and return it to the data collector. If you decide you do not want to participate, please return the blank survey to the data collector.
SNACS-II FOOD AND PHYSICAL ACTIVITY EXPERIENCES SURVEY
This survey asks about your participation at this center, the types of activities you do, and your experience with food at home.
DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really do and experience.
Completing the survey is voluntary. Whether or not you answer the questions will not affect your participation at this center. If you are not comfortable answering a question, just leave it blank.
Make sure to read every question. When you are finished, please return this survey to the data collector.
Please provide only one response per question unless otherwise instructed in the question.
Please answer questions by marking the box next to the option that best matches your answer.
Please answer questions by clearly writing your answer in the spaces provided or by marking the box next to the option that best matches your answer.
|
XIf you need to change a response, circle the correct item, and put a line through the incorrect item.
SECTION 1
1a. In the past week, at what time did you arrive at this center before school each day? At what time did you leave this center to go to school? If you did not go to the center before school on a day, mark the box for “I did not go to the center before school on this day.” Please write the times in the table below and circle AM or PM.
-
Day of the week
I did not go to the center before school on this day.
Time I arrived at the center before school:
Time I left the center to go to school:
Monday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Tuesday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Wednesday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Thursday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Friday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
1b. In the past week, at what time did you arrive at this center after school each day? At what time did you leave this center in the afternoon or evening? If you did not go to the center after school on a day, mark the box for “I did not go to the center after school on this day.” Please write the times in the table below and circle AM or PM.
-
Day of the week
I did not go to the center after school on this day.
Time I arrived at the center after school:
Time I left the center in the afternoon or evening:
Monday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Tuesday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Wednesday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Thursday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Friday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
1c. During the past weekend, at what time did you arrive at this center each day? At what time did you leave this center? Please write the times in the table below and circle AM or PM. If you did not go to the center on Saturday or Sunday, mark the box for “I did not go to the center on this day.”
-
Day of the week
I did not go to the center on this day.
Time I arrived at the center:
Time I left the center:
Saturday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
Sunday
1 □
| | | : | | | AM/PM
| | | : | | | AM/PM
SECTION 2
2. During the past 7 days, which kinds of physical activity did you do that increased your heart rate and made you breathe hard some of the time?
MARK ALL THAT APPLY
1 □ Football, soccer, basketball, baseball, softball, frisbee, or tennis
2 □ Running, jogging, or brisk walking
3 □ Hiking, bicycle riding, skateboarding, riding a scooter without a motor, swimming, or kayaking
4 □ Vigorous dancing, such as ballet, tap, salsa, hip-hop, or Zumba
5 □ Gymnastics or cheerleading
6 □ Martial arts, such as karate, taekwondo, or jiu-jitsu
7 □ House or yard work, such as sweeping or pushing a lawn mower
3a. During the past 7 days, on how many days were you physically active for a total of at least 30 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.
MARK ONE ONLY
0 0 DAYS
1 1 DAY
2 2 DAYS
3 3 DAYS
4 4 DAYS
5 5 DAYS
6 6 DAYS
7 7 DAYS
3b. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.
MARK ONE ONLY
0 0 DAYS
1 1 DAY
2 2 DAYS
3 3 DAYS
4 4 DAYS
5 5 DAYS
6 6 DAYS
7 7 DAYS
4. During the past 7 days, what kinds of exercises did you do to strengthen or tone your muscles?
MARK ALL THAT APPLY
1 □ Push-ups, pull-ups, or sit-ups
2 □ Weight lifting
3 □ Climbing (on rocks, ropes, trees, or playground equipment)
4 □ Yoga
5 □ Other (specify)
5. During the past 7 days, on how many days did you do any exercises to strengthen or tone your muscles?
MARK ONE ONLY
0 0 DAYS
1 1 DAY
2 2 DAYS
3 3 DAYS
4 4 DAYS
5 5 DAYS
6 6 DAYS
7 7 DAYS
6. In a usual week, on how many days do you go to physical education (PE) classes?
MARK ONE ONLY
0 0 DAYS
1 1 DAY
2 2 DAYS
3 3 DAYS
4 4 DAYS
5 5 DAYS
7. During the past 12 months, on how many sports teams did you play? Count any teams run by your school or community groups.
MARK ONE ONLY
0 0 TEAMS
1 1 TEAM
2 2 TEAMS
3 3 OR MORE TEAMS
SECTION 3
The following questions are about two different types of activities that use technology. The first activity is watching TV or videos. It includes time spent watching shows, movies, or video clips on a TV, phone, or computer. The second activity is playing video games, browsing the internet, or using social media. Social media includes apps for messaging or sharing photos or videos.
8a. On a usual school day, from the time you wake up until you go to bed, about how many hours do you spend watching TV or videos? Do not count time spent doing schoolwork.
MARK ONE ONLY
1 Less than 1 hour per day
2 1 hour per day
3 2 hours per day
4 3 hours per day
5 4 hours per day
6 5 hours or more per day
8b. On a usual school day, from the time you wake up until you go to bed, about how many hours do you spend playing video games, accessing the internet, or using social media? Do not count time spent doing schoolwork.
MARK ONE ONLY
1 Less than 1 hour per day
2 1 hour per day
3 2 hours per day
4 3 hours per day
5 4 hours per day
6 5 hours or more per day
9a. On a usual day when you don’t go to school, from the time you wake up until you go to bed, about how many hours do you spend watching TV or videos? Do not count time spent doing schoolwork.
MARK ONE ONLY
1 Less than 1 hour per day
2 1 hour per day
3 2 hours per day
4 3 hours per day
5 4 hours per day
6 5 hours or more per day
9b. On a usual day when you don’t go to school, from the time you wake up until you go to bed, about how many hours do you spend playing video games, accessing the internet, or using social media? Do not count time spent doing schoolwork.
MARK ONE ONLY
1 Less than 1 hour per day
2 1 hour per day
3 2 hours per day
4 3 hours per day
5 4 hours per day
6 5 hours or more per day
SECTION 4
The following questions are about the food situation in your home during the last month. Please mark the answer that best describes you.
10. Did you worry that food at home would run out before your family got money to buy more?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
11. Did the food that your family bought run out, and you didn’t have money to get more?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
12. Did your meals only include a few kinds of cheap foods because your family was running out of money to buy food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
13. How often were you not able to eat a balanced meal because your family didn’t have enough money?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
14. Did you have to eat less because your family didn’t have enough money to buy food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
15. Has the size of your meals been cut because your family didn’t have enough money for food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
16. Did you have to skip a meal because your family didn’t have enough money for food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
17. Were you hungry but didn’t eat because your family didn’t have enough food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
18. Did you not eat for a whole day because your family didn’t have enough money for food?
MARK ONE ONLY
1 A lot
2 Sometimes
3 Never
SECTION 5
These last questions are about your background. Your answers will help us describe the characteristics of youth who completed the survey.
19. How old are you?
MARK ONE ONLY
10 10 years old
11 11 years old
12 12 years old
13 13 years old
14 14 years old
15 15 years old
16 16 years old
17 17 years old
18 18 years old
20. How do you describe your gender?
MARK ONE ONLY
1 Male
2 Female
3 Non-binary/third gender
4 Prefer not to say
5 Prefer to self-describe:
21. In what grade are you?
MARK ONE ONLY
4 4th grade
5 5th grade
6 6th grade
7 7th grade
8 8th grade
9 9th grade
10 10th grade
11 11th grade
12 12th grade
13 Ungraded or other grade
22. Are you Hispanic, Latino, Latina, or Latinx?
1 Yes
2 No
23. What is your race?
MARK ALL THAT APPLY
1 □ American Indian or Alaska Native
2 □ Asian
3 □ Black or African American
4 □ Native Hawaiian or other Pacific Islander
5 □ White
Thank you very much for your help!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | MATHEMATICA |
| File Modified | 0000-00-00 |
| File Created | 2022-05-03 |
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