9th - 12th GRADE NUTRITION EDUCATION SURVEY

STUDENT’S CODE NUMBER_________________  DATE_________  ___ PRE	__ POST

DO NOT write your name on this survey.
The answers you give will be kept private. This survey is voluntary.

For each question, circle the answer that best describes you.
The first 4 questions ask about food you ate or drank.


1. Yesterday, how many times did you eat vegetables, not counting French fries?  Include cooked vegetables, canned vegetables and salads.  If you ate 2    different vegetables in a meal or snack, count them as 2 times.

0 - None
1 - 1 time
2 - 2 times
3 - 3 times
4 - 4+ times


2. Yesterday, how many times did you eat fruit, not counting juice? Include fresh, frozen, canned, and dried fruits.  If you ate 2 different fruits in a    meal or snack, count them as 2 times.

0 - None
1 - 1 time
2 - 2 times
3 - 3 times
4 - 4+ times


3. Yesterday, how many times did you drink non-fat or 1% low fat milk?  Include low fat chocolate or flavored milk, and low fat milk on cereal.

0 - None
1 - 1 time
2 - 2 times
3 - 3 times
4 - 4+ times


4. Yesterday, how many times did you drink sweetened drinks like soda, fruit-flavored drinks, sports drinks, energy drinks and vitamin water? Do not include    100% fruit juice.

N0 - None
1 - 1 time
2 - 2 times
3 - 3+ times


The next 2 questions ask about how often you choose certain foods.
 
5. When you eat grain products, how often do you eat whole grains, like brown rice instead of white rice, whole grain bread instead of white bread, and    whole grain cereals?

1 - Never
2 - Once in a while
3 - Sometimes
4- Most of the time
5 - Always


6. When you eat out at a restaurant or fast food place, how often do you make healthy choices when deciding what to eat?

1 - Never
2 - Once in a while
3 - Sometimes
4- Most of the time
5 - Always


The next 3 questions are about physical activity.


7. During the past 7 days, how many days were you physically active for at least 1 hour?

0 - 0 days
1 - 1 day
2 - 2 days
3 - 3 days
4 - 4 days
5 - 5 days
6 - 6 days
7 - 7 days

	
8. During the past 7 days, how often were you so active that your heart beat fast and you breathed hard most of the time?

1 - Never 
2 - 1 time last week
3 - 2 times last week
4 - 3 times last week
5 - 4 or more times last week


9. How many hours a day do you spend watching TV or movies, playing electronic games, or using a computer for something that is not school work?

1 - 1 hour or less
2 - 2 hours
3 - 3 hours
4 - 4 hours
5 - 5 or more hours

The next 5 questions are about how you handle food.

	
10. How often do you wash your hands before preparing something to eat?  Think about preparing snacks or meals.

1 - Never
2 - Once in a while
3 - Sometimes
4 - Most of the time
5 - Always


11. How often do you wash vegetables and fruits before eating them?

1 - Never
2 - Once in a while
3 - Sometimes
4 - Most of the time
5 - Always


12. When you take foods out of the refrigerator, how often do you put them back within 2 hours?

1 - Never
2 - Once in a while
3 - Sometimes
4 - Most of the time
5 - Always


13. How often do you check the expiration date before eating or drinking foods?

1 - Never
2 - Once in a while
3 - Sometimes
4 - Most of the time
5 - Always


14. In the last month, if your family did not have enough food, how often did you help by going to a food pantry or finding other free or low-cost food     resources?

0 - Does not apply
1 - Never
2 - 1 time
3 - 2 times
4 - 3 times
5 - 4 or more times


Developed by the EFNEP Youth Evaluation Committee                              Rev. 9/23/2014                                                 www.efnep.org

YOUTH EVALUATION0                                                                  Page 1 of 2                                   FISCAL YEAR 2015   Rev. 9/2/2014