Form 0920-24BJ Healthy Student Questionnaire

[NCCDPHP] Healthy Schools Program Evaluation

Attachment 11 - Healthy Student Questionnaire (highlighted for EO revision) 2025.05.02

Healthy Students Questionnaire

OMB: 0920-1455

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OMB No. 0920-xxxx
Expiration Date: XX/XX/XXXX


Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time needed for reviewing instructions. 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Healthy Students Questionnaire

Elementary School



Your school is part of a program to support student health during, before, and after the school day. This questionnaire will help us assess how well the program is working. These questions ask about health behaviors—like what you eat and drink and how active you are.  

Before you start, here are some important things we want you to know:  

  • This questionnaire should take about 20 minutes.

  • You do not have to do the questionnaire if you do not want to.

  • You do not have to answer any question you do not want to.

  • You will not provide your name so no one will know your answers to the questions.

  • The questions are not graded. Your grade in class will not change after you answer the questions.


If you have questions about this questionnaire please contact the evaluation team at 2302evaluation@icf.com. For questions regarding your rights related to this questionnaire you can contact ICF Institutional Review Board (IRB) at irb@icf.com.    

 

After reading the above information, if you agree to participate in the questionnaire click the arrow below.


  Thank you very much for your help! 












Section 1: General Information


Before you start, we need some basic information about you.


  1. What is your sex?

  1. Male

  2. Female

  3. Prefer not to answer


  1. What grade are you in?

  1. 4th

  2. 5th


  1. What is your race and/or ethnicity? Select all that apply.


    1. American Indian or Alaska Native – Provide details below.

Enter, for example, Navajo Nation, Blackfeet Tribe of Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

____________________________________________________________________

      • I don’t know


    1. Asian – Provide details below.

      • Chinese

      • Vietnamese

      • Asian Indian

      • Korean

      • Filipino

      • Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

________________________________________________________________________

      • I don’t know


    1. Black or African American – Provide details below.

      • African American

      • Nigerian

      • Jamaican

      • Ethiopian

      • Haitian

      • Somali

Enter, for example, Trinidadian and Tobagonian, Ghanian, Congolese, etc.

________________________________________________________________________

      • I don’t know


    1. Hispanic or Latino – Provide details below.

      • Mexican

      • Cuban

      • Puerto Rican

      • Dominican

      • Salvadoran

      • Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

_______________________________________________________________________

      • I don’t know


    1. Middle Eastern or North African

      • Lebanese

      • Syrian

      • Iranian

      • Iraqi

      • Egyptian

      • Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

_______________________________________________________________________

      • I don’t know


    1. Native Hawaiian or Other Pacific Islander

      • Native Hawaiian

      • Tongan

      • Samoan

      • Fijian

      • Chamorro

      • Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

_______________________________________________________________________

      • I don’t know


    1. White

      • English

      • Italian

      • German

      • Polish

      • Irish

      • Scottish

Enter, for example, French, Swedish, Norwegian, etc.

________________________________________________________________________

      • I don’t know


  1. During the 2023–2024 school year, did you participate in a before- or after-school program?  

  1. Yes 

  2. No  


  1. During the 2023–2024 school year, did you participate in a sports team or take sports lessons after school or on weekends?  

  1. Yes 

  1. No  


Section 2: Physical Activity Behaviors


The next 11 questions are about physical activity behaviors.


Physical activity behaviors are activities that involve walking, running, rolling (in a wheelchair or on a scooter or skateboard), or moving around. They include biking, dancing, sports, or outdoor play that involves a lot of moving around.


SCHOOL: Activity Levels at School


Tell us about the activity you do at school. Answer the questions based on the last 7 days.


  1. Activity to school: How many days did you walk, bike, or roll (in a wheelchair or on a scooter or skateboard) to school? If you can’t remember, try to estimate.

  1. 0 days (never)

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4-5 days (almost every day)


  1. Activity during physical education class: During physical education, how often were you running, rolling (in a wheelchair or on a scooter or skateboard), and moving as part of the planned games or activities? If you didn’t have physical education, choose “I didn’t have physical education.”

  1. I didn’t have physical education

  2. Almost none of the time

  3. A little bit of the time

  4. A moderate amount of the time

  5. A lot of the time

  6. Almost all of the time


  1. Activity during recess: During recess, how often were you playing sports, walking, running, rolling (in a wheelchair or on a scooter or skateboard), or playing active games? If you didn’t have a break at school, choose “I didn’t have recess.”

  1. I didn’t have recess

  2. Almost none of the time

  3. A little bit of the time

  4. A moderate amount of the time

  5. A lot of the time

  6. Almost all of the time


  1. Activity during class: During school, how often did you engage in classroom “activity breaks” that involve standing, rolling (in a wheelchair or on a scooter or skateboard), or moving around for 5 minutes or more as part of normal class activities (other than physical education and recess)?

  1. Less than once per week

  2. 1-2 times per week

  3. 3-4 times per week

  4. 5 times per week (every day)

  5. More than once per day


  1. Activity from school: How many days did you walk, bike, or roll (in a wheelchair or on a scooter or skateboard) home from school? If you can’t remember, try to estimate.

  1. 0 days (never)

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4-5 days (almost every day)



OUTSIDE OF SCHOOL: Activity Levels Outside of School


Tell us about your activity when you are not at school. Answer the questions based on the last 7 days.


  1. Activity before school: How many days before school (6:00 – 8:00 am) did you do some form of physical activity for at least 10 minutes? This includes activity at home, NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) to school.

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4-5 days


  1. Activity after school: How many days after school (between 3:00 – 6:00 pm) did you do some form of physical activity for at least 10 minutes? This can include playing with your friends/family, team practices or classes involving physical activity, but NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) home from school.

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4-5 days


  1. Activity on weeknights: How many school evenings (6:00 – 10:00 pm) did you do some form of physical activity for at least 10 minutes? This can include playing with your friends/family, team practices or classes involving physical activity, but NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) home from school.

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4-5 days


  1. Activity on Saturday: How much physical activity did you do last Saturday? This could be for exercise, work/chores, family outings, sports, dance, or play. If you don’t remember, try to estimate.

  1. No activity (0 minutes)

  2. Small amount of activity (1 to 30 minutes)

  3. Small to moderate amount of activity (31 to 60 minutes)

  4. Moderate to large amount of activity (1 to 2 hours)

  5. Large amount of activity (more than 2 hours)


  1. Activity on Sunday: How much physical activity did you do last Sunday? This could be for exercise, work/chores, family outings, sports, dance, or play. If you don’t remember, try to estimate.

  1. No activity (0 minutes)

  2. Small amount of activity (1 to 30 minutes)

  3. Small to moderate amount of activity (31 to 60 minutes)

  4. Moderate to large amount of activity (1 to 2 hours)

  5. Large amount of activity (more than 2 hours)


Now please tell us about your overall physical activity.


  1. Last week, on which 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. Examples include: Basketball, soccer, running or jogging, fast dancing, swimming laps, tennis, fast bicycling, fast rolling (wheelchair, scooter, skateboard), or similar aerobic activities.

Check yes or no for each day

Monday

  • Yes

  • No

Tuesday

  • Yes

  • No

Wednesday

  • Yes

  • No

Thursday

  • Yes

  • No

Friday

  • Yes

  • No

Saturday

  • Yes

  • No

Sunday

  • Yes

  • No


Section 3: Dietary Behaviors


The next 13 questions are about dietary behaviors.


Tell us about the foods and beverages you consume. Answer the questions based on what you did yesterday.


  1. Yesterday, did you eat breakfast?

  1. Yes

  2. No


  1. [If yes] Yesterday, did you eat breakfast at school?

  1. Yes

  2. No


  1. Yesterday, did you buy your lunch at school? (Choose no if you brought your lunch from home).

A. Yes

B. No


The next questions are about what you ate and drank yesterday at school. Think about foods you got in the school cafeteria or classroom, bought from a vending machine or school store, or were given to you as a treat or reward. Focus on foods you ate and beverages you drank during the school day up until the last bell. Do not include foods or drinks you brought from home for your lunch or for snacks. Do count foods and drinks you had as part of classroom or school events, like birthdays.


  1. Yesterday at school, did you eat any vegetables? Vegetables are all cooked and uncooked vegetables; salads; and boiled, baked, and mashed potatoes.


Do not count French fries, tater tots, or chips.

  1. No, I didn’t eat any vegetables yesterday at school.

  2. Yes, I ate vegetables 1 time yesterday at school.

  3. Yes, I ate vegetables 2 times yesterday at school.

  4. Yes, I ate vegetables 3 times yesterday at school.

  5. Yes, I ate vegetables 4 times yesterday at school.

  6. Yes, I ate vegetables 5 or more times yesterday at school.


  1. Yesterday at school, did you eat fruit or berries? Include fresh or frozen fruit or berries, and dried or canned fruit or berries, such as fruit cups and raisins.


Do not count fruit juice.

  1. No, I didn’t eat any fruit or berries yesterday at school.

  2. Yes, I ate fruit or berries 1 time yesterday at school.

  3. Yes, I ate fruit or berries 2 times yesterday at school.

  4. Yes, I ate fruit or berries 3 times yesterday at school.

  5. Yes, I ate fruit or berries 4 times yesterday at school.

  6. Yes, I ate fruit or berries 5 or more times yesterday at school.


  1. Yesterday at school, did you drink any water, such as from a glass, a bottle, or a water fountain?

  1. No, I didn’t drink any water yesterday at school.

  2. Yes, I drank water 1 time yesterday at school.

  3. Yes, I drank water 2 times yesterday at school.

  4. Yes, I drank water 3 times yesterday at school.

  5. Yes, I drank water 4 times yesterday at school.

  6. Yes, I drank water 5 or more times yesterday at school.


  1. Yesterday at school, did you drink any sports drinks?


  1. No, I didn’t drink any of these drinks yesterday at school.

  2. Yes, I drank one of these drinks 1 time yesterday at school.

  3. Yes, I drank one of these drinks 2 times yesterday at school.

  4. Yes, I drank one of these drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you drink any punch or other fruit-flavored drinks?


Do not count 100% fruit juice or diet drinks.

  1. No, I didn’t drink any of these drinks yesterday at school.

  2. Yes, I drank one of these drinks 1 time yesterday at school.

  3. Yes, I drank one of these drinks 2 times yesterday at school.

  4. Yes, I drank one of these drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you drink any regular (not diet) sodas or soft drinks?

  1. No, I didn’t drink any regular (not diet) sodas or soft drinks yesterday at school.

  2. Yes, I drank regular (not diet) sodas or soft drinks 1 time yesterday at school.

  3. Yes, I drank regular (not diet) sodas or soft drinks 2 times yesterday at school.

  4. Yes, I drank regular (not diet) sodas or soft drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you eat French fries, tater tots, or chips? Chips are potato chips, tortilla chips, corn chips, taro chips, or other snack chips.

  1. No, I didn’t eat any French fries, tater tots, or chips yesterday at school.

  2. Yes, I ate French fries, tater tots, or chips 1 time yesterday at school.

  3. Yes, I ate French fries, tater tots, or chips 2 times yesterday at school.

  4. Yes, I ate French fries, tater tots, or chips 3 or more times yesterday at school.


  1. Yesterday at school, did you eat, donuts, malasadas/andagi, cinnamon rolls, cookies, brownies, pies, or cake?  

    1. No, I didn’t eat any of these foods yesterday at school.

    2. Yes, I ate one of these foods 1 time yesterday at school.

    3. Yes, I ate one of these foods 2 times yesterday at school.

    4. Yes, I ate one of these foods 3 or more times yesterday at school.


  1. Yesterday at school, did you eat a frozen treat? A frozen treat is a cold, sweet food like ice cream or an ice cream bar, frozen yogurt, a Popsicle, or shaved ice.


  1. No, I didn’t eat any frozen treats yesterday at school.

  2. Yes, I ate a frozen treat 1 time yesterday at school.

  3. Yes, I ate a frozen treat 2 times yesterday at school.

  4. Yes, I ate a frozen treat 3 or more times yesterday at school.


  1. Yesterday at school, did you eat any candy? Do not count brownies, cookies, or gum.

  1. No, I didn’t eat any candy yesterday at school.

  2. Yes, I ate candy 1 time yesterday at school.

  3. Yes, I ate candy 2 times yesterday at school.

  4. Yes, I ate candy 3 or more times yesterday at school.


Section 4: Chronic Health Conditions (and Other Conditions)


The next 2 questions are about chronic health conditions and other conditions.


  1. Has a doctor or nurse ever said you have a chronic health condition? A chronic health condition is a condition that lasts a long time or goes away but keeps coming back. Diabetes, allergies, and asthma are examples of chronic health conditions.

  1. Yes

  2. No

  3. Not sure


  1. [If yes to 30] Do you feel people at your school help you take care of your chronic health condition?

  1. Yes

  2. No

  3. Not sure


Section 6: School Connectedness, Emotions, and Grades


The next 7 questions are about school connectedness.


School connectedness is the belief that your friends, teachers, and other adults in your school support, value, and care about your health and how you are doing in school.


How much do you agree or disagree with the following statements?


  1. I feel close to people at school.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. Teachers care about me.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. I feel happy at school.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. I feel like I am part of my school.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. I feel teachers treat students fairly.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. I feel safe in my school.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school? If you can’t remember, try to estimate.

  1. 0 days

  2. 1 day

  3. 2 or 3 days

  4. 4 or 5 days

  5. 6 or more days


The next 2 questions are about your emotions.


How much do you agree or disagree with the following statements?


  1. When I set my mind to something, I can take steps to make it happen.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


  1. When something upsetting happens to me, I deal with my emotions well.

  1. Strongly disagree

  2. Disagree

  3. Neither agree nor disagree

  4. Agree

  5. Strongly agree


The next question is about your grades.


  1. During the past 12 months, how would you describe your grades in school?

  1. Mostly A’s

  2. Mostly B’s

  3. Mostly C’s

  4. Mostly D’s

  5. Mostly F’s

  6. None of these grades

  7. Not sure


Thank you for responding to this survey!


You can find health information for kids at the following website:


USDA MyPlate Nutrition Information for Kids

www.myplate.gov/life-stages/kids



Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions. 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Healthy Students Questionnaire

Middle and High School

Your school is part of a program to support student health during, before, and after the school day. This questionnaire will help us assess how well the program is working. These questions ask about health behaviors—like what you eat and drink and how active you are.  

Before you start, here are some important things we want you to know:  

  • The questionnaire should take less than 30 minutes to complete.

  • This questionnaire is voluntary. That means you don’t have to do it if you don’t want to. 

  • If you are not comfortable answering a question, just leave it blank.

  • You will not provide your name so no one will know your answers to the questions.

  • This questionnaire will not be graded and will not affect your grade in this class. 

  • Questions about your background will only be used to describe the backgrounds of students completing this questionnaire, not to identify you. 

 

Take your time and read every question. Answer the questions as best as you can and report on what you really do rather than what you think you should do, or others say you should do. When you are finished, follow the instructions of the person giving you the questionnaire. 


If you have questions about this questionnaire please contact the evaluation team at 2302evaluation@icf.com. For questions regarding your rights related to this questionnaire you can contact ICF Institutional Review Board (IRB) chair at irb@icf.com

 

After reading the above information, if you agree to participate in the questionnaire click the arrow below.


  Thank you very much for your help! 







Section 1: General Information


Before you start, we need some basic information about you.


  1. What is your sex?

  1. Male

  2. Female

  3. Prefer not to answer


  1. What grade are you in?

  1. 6th 

  2. 7th 

  3. 8th 

  4. 9th 

  5. 10th 

  6. 11th 

  7. 12th 


  1. What is your race and/or ethnicity? Select all that apply.

    1. American Indian or Alaska Native – Provide details below.

      • Enter, for example, Navajo Nation, Blackfeet Tribe of Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

____________________________________________________________________

  1. I don’t know


  1. Asian – Provide details below.

      • Chinese

      • Vietnamese

      • Asian Indian

      • Korean

      • Filipino

      • Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

________________________________________________________________________

      • I don’t know

    1. Black or African American – Provide details below.

      • African American

      • Nigerian

      • Jamaican

      • Ethiopian

      • Haitian

      • Somali

Enter, for example, Trinidadian and Tobagonian, Ghanian, Congolese, etc.

________________________________________________________________________

      • I don’t know

    1. Hispanic or Latino – Provide details below.

      • Mexican

      • Cuban

      • Puerto Rican

      • Dominican

      • Salvadoran

      • Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

_______________________________________________________________________

  1. I don’t know


    1. Middle Eastern or North African

      • Lebanese

      • Syrian

      • Iranian

      • Iraqi

      • Egyptian

      • Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

_______________________________________________________________________

  1. I don’t know


    1. Native Hawaiian or Other Pacific Islander

      • Native Hawaiian

      • Tongan

      • Samoan

      • Fijian

      • Chamorro

      • Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

_______________________________________________________________________

  1. I don’t know


    1. White

      • English

      • Italian

      • German

      • Polish

      • Irish

      • Scottish

Enter, for example, French, Swedish, Norwegian, etc.

________________________________________________________________________

      • I don’t know


  1. During the 2023–2024 school year, did you participate in a before- or after-school program?  

  1. Yes

  2. No


  1. During the 2023–2024 school year, did you participate in a sports team or take sports lessons before or after school or on weekends?  

  1. Yes

  2. No


Section 2: Physical Activity Behaviors


The next 12 questions are about physical activity behaviors.


Physical activity behaviors are activities that involve walking, running, rolling (in a wheelchair or on a scooter or skateboard), or moving around. They include biking, dancing, sports, or outdoor play that involves a lot of moving around.


SCHOOL: Activity Levels at School


Tell us about the activity you do at school. Answer the questions based on the last 7 days.


  1. Activity to school: How many days did you walk, bike, or roll (in a wheelchair or on a scooter or skateboard) to school? If you can’t remember, try to estimate.

  1. 0 days (never)

  1. 1 day

  2. 2 days

  3. 3 days

  4. 4-5 days (almost every day)


  1. Activity during physical education class: During physical education, how often were you running, rolling (in a wheelchair or on a scooter or skateboard), and moving as part of the planned games or activities? If you didn’t have physical education, choose “I didn’t have physical education.”

  1. I didn’t have physical education

  1. Almost none of the time

  2. A little bit of the time

  3. A moderate amount of the time

  4. A lot of the time

  5. Almost all of the time


  1. Activity during recess: During recess, how often were you playing sports, walking, running, rolling (in a wheelchair or on a scooter or skateboard), or playing active games? If you didn’t have a break at school, choose “I didn’t have recess.”

  1. I didn’t have recess

  1. Almost none of the time

  2. A little bit of the time

  3. A moderate amount of the time

  4. A lot of the time

  5. Almost all of the time


  1. Activity during class: During school, how often did you engage in classroom “activity breaks” that involve standing or moving around for 5 minutes or more as part of normal class activities (other than physical education and recess)?

  1. Less than once per week

  1. 1-2 times per week

  2. 3-4 times per week

  3. 5 times per week (every day)

  4. More than once per day


  1. Activity from school: How many days did you walk, bike, or roll (in a wheelchair or on a scooter or skateboard) home from school? If you can’t remember, try to estimate.

  1. 0 days (never)

  1. 1 day

  2. 2 days

  3. 3 days

  4. 4-5 days (almost every day)



OUTSIDE OF SCHOOL: Activity Levels Outside of School


Tell us about your activity when you are not at school. Answer the questions based on the last 7 days.


  1. Activity before school: How many days before school (6:00 – 8:00 am) did you do some form of physical activity for at least 10 minutes? This includes activity at home, NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) to school.

  1. 0 days

  1. 1 day

  2. 2 days

  3. 3 days

  4. 4-5 days


  1. Activity after school: How many days after school (between 3:00 – 6:00 pm) did you do some form of physical activity for at least 10 minutes? This can include playing with your friends/family, team practices or classes involving physical activity, but NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) home from school.

  1. 0 days

  1. 1 day

  2. 2 days

  3. 3 days

  4. 4-5 days


  1. Activity on weeknights: How many school evenings (6:00 – 10:00 pm) did you do some form of physical activity for at least 10 minutes? This can include playing with your friends/family, team practices or classes involving physical activity, but NOT walking, biking, or rolling (in a wheelchair or on a scooter or skateboard) home from school.

  1. 0 days

  1. 1 day

  2. 2 days

  3. 3 days

  4. 4-5 days


  1. Activity on Saturday: How much physical activity did you do last Saturday? This could be for exercise, work/chores, family outings, sports, dance, or play. If you don’t remember, try to estimate.

  1. No activity (0 minutes)

  1. Small amount of activity (1 to 30 minutes)

  2. Small to moderate amount of activity (31 to 60 minutes)

  3. Moderate to large amount of activity (1 to 2 hours)

  4. Large amount of activity (more than 2 hours)


  1. Activity on Sunday: How much physical activity did you do last Sunday? This could be for exercise, work/chores, family outings, sports, dance, or play. If you don’t remember, try to estimate.

  1. No activity (0 minutes)

  1. Small amount of activity (1 to 30 minutes)

  2. Small to moderate amount of activity (31 to 60 minutes)

  3. Moderate to large amount of activity (1 to 2 hours)

  4. Large amount of activity (more than 2 hours)


Now please tell us about your overall physical activity. Answer the question based on the last 7 days.

  1. Last week, on which 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. Examples include: Basketball, soccer, running or jogging, fast dancing, swimming laps, tennis, fast bicycling, fast rolling (wheelchair, scooter, skateboard), or similar aerobic activities.

Check yes or no for each day

Monday

  • Yes

  • No

Tuesday

  • Yes

  • No

Wednesday

  • Yes

  • No

Thursday

  • Yes

  • No

Friday

  • Yes

  • No

Saturday

  • Yes

  • No

Sunday

  • Yes

  • No


  1. During the past 7 days, on how many days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weightlifting?”

  1. 0 days

  2. 1 day

  3. 2 days

  4. 3 days

  5. 4 days

  6. 5 days

  7. 6 days

  8. 7 days

Section 3: Dietary Behaviors


The next 13 questions are about dietary behaviors.


Tell us about the foods and beverages you consume. Answer the questions based on what you did yesterday.


  1. Yesterday, did you eat breakfast?

  1. Yes

  1. No


  1. [If yes] Yesterday, did you eat breakfast at school?

  1. Yes

  1. No


  1. Yesterday, did you buy your lunch at school? (Choose no if you brought your lunch from home)

  1. Yes

  2. No


The next questions are about what you ate and drank yesterday at school. Think about foods you got in the school cafeteria or classroom, bought from a vending machine or school store, or were given to you as a treat or reward. Focus on foods you ate and beverages you drank during the school day up until the last bell. Do not include foods or drinks you brought from home for your lunch or for snacks. Do count foods and drinks you had as part of classroom or school events, like birthdays.


  1. Yesterday at school, did you eat any vegetables? Vegetables are all cooked and uncooked vegetables; salads; and boiled, baked, and mashed potatoes.


Do not count French fries, tater tots, or chips.

  1. No, I didn’t eat any vegetables yesterday at school.

  1. Yes, I ate vegetables 1 time yesterday at school.

  2. Yes, I ate vegetables 2 times yesterday at school.

  3. Yes, I ate vegetables 3 times yesterday at school.

  4. Yes, I ate vegetables 4 times yesterday at school.

  5. Yes, I ate vegetables 5 or more times yesterday at school.


  1. Yesterday at school, did you eat fruit or berries? Include fresh or frozen fruit or berries, and dried or canned fruit or berries, such as fruit cups and raisins.


Do not count fruit juice.

  1. No, I didn’t eat any fruit or berries yesterday at school.

  1. Yes, I ate fruit or berries 1 time yesterday at school.

  2. Yes, I ate fruit or berries 2 times yesterday at school.

  3. Yes, I ate fruit or berries 3 times yesterday at school.

  4. Yes, I ate fruit or berries 4 times yesterday at school.

  5. Yes, I ate fruit or berries 5 or more times yesterday at school.


  1. Yesterday at school, did you drink any water, such as from a glass, a bottle, or a water fountain?

  1. No, I didn’t drink any water yesterday at school.

  1. Yes, I drank water 1 time yesterday at school.

  2. Yes, I drank water 2 times yesterday at school.

  3. Yes, I drank water 3 times yesterday at school.

  4. Yes, I drank water 4 times yesterday at school.

  5. Yes, I drank water 5 or more times yesterday at school.


  1. Yesterday at school, did you drink any sports drinks?


  1. No, I didn’t drink any of these drinks yesterday at school.

  1. Yes, I drank one of these drinks 1 time yesterday at school.

  2. Yes, I drank one of these drinks 2 times yesterday at school.

  3. Yes, I drank one of these drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you drink any punch or other fruit-flavored drinks?


Do not count 100% fruit juice or diet drinks.

  1. No, I didn’t drink any of these drinks yesterday at school.

  1. Yes, I drank one of these drinks 1 time yesterday at school.

  2. Yes, I drank one of these drinks 2 times yesterday at school.

  3. Yes, I drank one of these drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you drink any regular (not diet) sodas or soft drinks?

  1. No, I didn’t drink any regular (not diet) sodas or soft drinks yesterday at school.

  1. Yes, I drank regular (not diet) sodas or soft drinks 1 time yesterday at school.

  2. Yes, I drank regular (not diet) sodas or soft drinks 2 times yesterday at school.

  3. Yes, I drank regular (not diet) sodas or soft drinks 3 or more times yesterday at school.


  1. Yesterday at school, did you eat French fries, tater tots, or chips? Chips are potato chips, tortilla chips, corn chips, taro chips, or other snack chips.

  1. No, I didn’t eat any French fries, tater tots, or chips yesterday at school.

  1. Yes, I ate French fries, tater tots, or chips 1 time yesterday at school.

  2. Yes, I ate French fries, tater tots, or chips 2 times yesterday at school.

  3. Yes, I ate French fries, tater tots, or chips 3 or more times yesterday at school.


  1. Yesterday at school, did you eat donuts, malasadas/andagi, cinnamon rolls, cookies, brownies, pies, or cake?   

  1. No, I didn’t eat any of these foods yesterday at school.

  1. Yes, I ate one of these foods 1 time yesterday at school.

  2. Yes, I ate one of these foods 2 times yesterday at school.

  3. Yes, I ate one of these foods 3 or more times yesterday at school.


  1. Yesterday at school, did you eat a frozen treat? A frozen treat is a cold, sweet food like ice cream or an ice cream bar, frozen yogurt, a Popsicle, or shaved ice. 

  1. No, I didn’t eat any frozen treats yesterday at school.

  2. Yes, I ate a frozen treat 1 time yesterday at school.

  3. Yes, I ate a frozen treat 2 times yesterday at school.

  4. Yes, I ate a frozen treat 3 or more times yesterday at school.


  1. Yesterday at school, did you eat any candy? Do not count brownies, cookies, or gum.

  1. No, I didn’t eat any candy yesterday at school.

  1. Yes, I ate candy 1 time yesterday at school.

  2. Yes, I ate candy 2 times yesterday at school.

  3. Yes, I ate candy 3 or more times yesterday at school.


The next 2 questions are about food insecurity.


  1. During the past 12 months, how often was your family worried that your food would run out before you got money to buy more?

  1. Never

  2. Sometimes

  3. Often


  1. During the past 12 months, how often did the food your family bought not last and they did not have money to get more?

  1. Never

  2. Sometimes

  3. Often


Section 4: Chronic Health Conditions (and Other Conditions)


The next 2 questions are about chronic health conditions and other conditions.


  1. Has a doctor or nurse ever said you have a chronic health condition? A chronic health condition is a condition that lasts a long time or goes away but keeps coming back. Chronic health conditions may include asthma, diabetes, food allergies, epilepsy, and other physical conditions, such as teeth or gum problems.

  1. No, I have never been told I have a chronic health condition.

  1. Yes, but I do not currently have a chronic health condition.

  2. Yes, I currently have a chronic health condition.

  3. Not sure


  1. [If yes to 33] Do you feel like you get the support you need at school to manage your chronic health condition? This support can be providing necessary daily medications, having a school nurse on staff to answer questions, and offering education about your health condition(s).

  1. Yes

  1. No

  2. Not sure


Section 5: School Connectedness, Emotions, and Grades

The next 7 questions are about school connectedness.


School connectedness is the belief that your friends, teachers, and other adults in your school support, value, and care about your health and how you are doing in school.


How much do you agree or disagree with the following statements?


  1. I feel close to people at school.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. Teachers care about me.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. I feel happy at school.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. I feel like I am part of my school.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. I feel teachers treat students fairly.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. I feel safe in my school.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school? If you can’t remember, try to estimate.

    1. 0 days

    2. 1 day

    3. 2 or 3 days

    4. 4 or 5 days

    5. 6 or more days


The next 3 questions are about your emotions.


How much do you agree or disagree with the following statements?


  1. When I set my mind to something, I can take steps to make it happen.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. When something upsetting happens to me, I deal with my emotions well.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


  1. I feel positive about my future.

  1. Strongly disagree

  1. Disagree

  2. Neither agree nor disagree

  3. Agree

  4. Strongly agree


The next question is about your mental health.


  1. During the past 30 days, how often was your mental health not good? (Poor mental health includes stress, anxiety, and depression.)

  1. Never

  1. Rarely

  2. Sometimes

  3. Most of the time

  4. Always


The next question is about your grades.


  1. During the past 12 months, how would you describe your grades in school?

  1. Mostly A’s

  1. Mostly B’s

  2. Mostly C’s

  3. Mostly D’s

  4. Mostly F’s

  5. None of these grades

  6. Not sure




Thank you for responding to this survey!



You can find health information for teens at the following websites:


USDA MyPlate Nutrition Information for Teens

www.myplate.gov/life-stages/teens


Teen Mental Health: MedlinePlus

www.medlineplus.gov/teenmentalhealth.html



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