1995-96 1997-98 California Student Survey of Substance Use And by fionan

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									                                 Middle School Post Test

                        Sample School Attitude and Behavior
                              Questionnaire (7th-12th)

           This is a survey about diet and physical activity.

           Whether or not you have ever done any of these things, please answer all the questions.
           You will be able to answer that you have not done them.

           Please do not write your name on this form.

           Please mark all of your answers on this questionnaire.
           Mark only one answer unless told to “Mark All That Apply.”

           If you need help with any part of this questionnaire, please ask the person who handed out
            the questionnaire to help you. Part of her/his job is to answer your questions.

                                         Thank you for taking this survey!


Fill in the bubble that corresponds to your answer right on this form.


S1.     What school do you attend?
            
            
            
            


S2.     What is your grade level?
           7th                                10th                    Other
                  th
             8                                11th
             9th                              12th


S3.     Put the first letter of your first name here:
        Put the last letter of your last name here:
        Put the month and date you were born:
        E.g. August 9 would be 08 / 09



S4.     Are you female (girl) or male (boy)?
             Female (girl)
             Male (boy)
      San Mateo Study 2005-07                                          Middle School Post Questionnaire
      Year 3 April 2008
                                  Middle School Post Test
S5.      How do you describe yourself?
         Mark All That Apply.
                Native Hawaiian or Pacific Islander (e.g. Samoan, Tongan)
                Asian
                Filipino
                Black or African American (non-Hispanic)
                Hispanic or Latino/Latina
                White or Caucasian (non-Hispanic)
                Other.

S6.      During an average physical education (P.E.) class, how many minutes do you spend actually
         exercising or playing sports?
              I do not take P.E
              Less than 20 minutes
              20-40 minutes
              More than 40 minutes.

S7.      During the past 12 months, on how many sports teams did you play?
         Include school sponsored teams and any other sports teams.
                0 teams
                1 team
                2 teams
                3 or more teams.

S8.      During the past 12 months, how many types of organized physical activity did you take part in
         at school or outside of school? Include dance clubs, hiking groups, gymnastics etc.
              0
              1
              2
              3 or more.

S9.      During the past 12 months, how many types of casual physical activity did you take part in?
         Include skateboarding, jogging, working out at the gym, gardening etc.
                0
                1
                2
                3 or more.

S10.     Are there any reasons keeping you from doing physical activity after school?
             There is no place safe
             Lack of choices in activities offered (e.g. no dance, skateboarding, different sports)
             Not enough spare time/too busy
             I can‟t motivate myself
             I don‟t want to do physical activity
             There is no reason.




       San Mateo Study 2005-07                                               Middle School Post Questionnaire
       Year 3 April 2008
                                   Middle School Post Test

On how many of the past 7 days did you...
                                                                                            Number of days
                                                                         0       1      2        3        4       5   6       7
 S11.      Exercise or do a physical activity for at least 20
                                                                                                                       
           minutes that made you sweat and breathe hard?
           E.g. play basketball, soccer, running, swimming laps,
           fast bicycling, fast dancing or similar aerobic activities.

 S12.      Participate in a physical activity for at least 30
                                                                                                                       
           minutes that did not make you sweat and breathe
           hard? E.g. fast walking, slow bicycling, shooting
           baskets, skating, raking leaves, and mopping floors.

 S13.      Do exercises to strengthen or tone your muscles?
           E.g. do push-ups, sit-ups, or weightlifting.                                                                



In an average week, where do you eat most of your meals? E.g. if you eat a meal for breakfast at home four
times a week or more, fill in the bubble under ‘at home’ in the ‘Breakfast’ row. If you eat at home 3 times a week and at
school 3 times a week, you may fill in both bubbles.

                               At home       At school         At a   At a fast- At another               Other       I do not
                                                             friend’s   food      kind of                             eat this
                                                              house restaurant restaurant                               meal

 S14.      Breakfast                O             O              O           O               O                O           O

 S15.      Lunch                    O             O              O           O               O                O           O

 S16.      Dinner                   O             O              O           O               O                O           O


Can you buy these things at school? (in cafeteria, vending machines, school store etc.)
                                                                             Yes                     No

 S17.      Soda                                                                                     

 S18.      Chips                                                                                    

 S19.      Candy                                                                                    




     San Mateo Study 2005-07                                                     Middle School Post Questionnaire
     Year 3 April 2008
                                   Middle School Post Test
During the past 24 hours (yesterday), how many times did you...
                                                                    0         1          2        3         4       5 or
                                                                  times     time       times    times     times     more
S20.      Drink milk or eat yogurt?
          In any form, including in cereal.                                                                       

S21.      Drink soda pop?
                                                                                                                  
S22.      Drink 100% fruit juices, such as orange, apple?
          Do not count punch, Kool-Aid, sports drinks and other
                                                                                                                  
          fruit-flavored drinks.
S23.      Eat french fries, potato chips, or other fried
                                                                                                                  
          potatoes?
S24.      Eat vegetables? Include salads and nonfried potatoes.
                                                                                                                  
S25.      Eat fruit? Do not count fruit juice.
                                                                                                                  
S26.      Eat sweets? E.g. baked goods, candy, ice cream,
          cookie, candy bar, other candy.
                                                                                                                  


How easy is it to get the following foods at school?
                                                                  Very      Somewhat           Not Easy           Don’t
                                                                  Easy        Easy              at all            know
S27.     Fresh Fruit
                                                                                                                
S28.     Vegetables (cooked or raw, like carrot snack packs)
                                                                                                                
S29.     Low fat yogurt
                                                                                                                
S30.     Low fat milk
                                                                                                                
S31.     100% fruit juice
                                                                                                                

S32.     I eat foods that are healthy…
                  Every day
                  Most days
                  Some days
                  Never or almost never.

S33.     How do you describe your weight?
                Very underweight
                Slightly underweight
                About the right weight
                Slightly overweight
                Very overweight.



       San Mateo Study 2005-07                                            Middle School Post Questionnaire
       Year 3 April 2008
                                    Middle School Post Test
S34.     How do you feel about your body? Mark all that apply.
                Want to lose weight
                Want to gain weight
                Want to be more fit
                Want to build my muscles
                I like it the way it is.

S35.     On an average school day, how many hours do you watch TV, play video games,
         or surf the internet?
                  I do not watch TV, play video games, or surf the internet on an average school day
                  Less than 1 hour per day
                  About 1 hour per day
                  About 2 hours per day
                  About 3 hours per day
                  4 or more hours per day.

S36.    On a usual weekend day, how many hours do you watch TV play video games,
        or surf the internet, from the time you get up until you go to bed?
                 Less than 1 hour
                 About 1 - 2 hours
                 About 3 - 4 hours
                 About 5 - 7 hours
                 7 or more hours.

S37.     In the last 7 days, how many times did you eat a meal or snack from a fast food restaurant?
         E.g. McDonald’s, Pizza Hut, Burger King, KFC, Taco Bell etc.
                      0 times
                      1 time
                      2 - 3 times
                      4 - 6 times
                      7 - 10 times
                      More than 10 times.

S38.     How many servings of vegetables do you eat on average each day?
         One serving is about the size of your fist (e.g. a carrot or a bowl of salad).
                      0 servings
                      1 serving
                      2 - 3 servings
                      4 - 5 servings
                      More than 5 servings.

S39.     Who decides what food is served at your home?
                I decide
                My family and I decide together
                My parent(s) decide.




       San Mateo Study 2005-07                                                    Middle School Post Questionnaire
       Year 3 April 2008
                                 Middle School Post Test
S40. How often do you get the school breakfast?
              Every day
              Most days
              Some days
              Never or almost never
              Our school does not serve breakfasts.

S41. How many cans of soda pop should kids your age be allowed to drink each day?
             None
             1 can each day
             2 -3 cans each day
             4 cans
             As much as they want.

S42.    How many servings of candy should kids your age be allowed to eat each day?
               None
               1 serving each day
               2 -3 servings each day
               4 servings each day
               As much as they want.

S43.     How often do you get the school lunch?
                Usually or every day
                Most days
                Some days
                Never or almost never.

S44.     How many servings of fruit and vegetables do STUDENTS your age need to eat each day?
               No servings, as long as they take vitamins
               1 serving each day
               2 servings each day
               3 - 4 servings each day
               5 - 6 servings each day
               7 or more servings each day.

S45.     How many minutes of physical activity (e.g., walking, running, bicycling, etc.) each day do
         school students your age need for good health?
                  At least 10 minutes each day
                  At least 20 minutes each day
                  At least 30 minutes each day
                  At least 40 minutes each day
                  At least 50 minutes each day
                  At least 60 minutes each day
                  Students do not need to do physical activity everyday.




       San Mateo Study 2005-07                                        Middle School Post Questionnaire
       Year 3 April 2008
                                    Middle School Post Test
S46.     During the past 12 months, how would you describe the grades you mostly received in school?
                 Mostly A‟s
                 A‟s and B‟s
                 Mostly B‟s
                 B‟s and C‟s
                 Mostly C‟s
                   C‟s and D‟s
                   Mostly D‟s and F‟s.

S47.     The number one reason I eat the school lunch is: Mark only one.
                It‟s free or cheap
                The food is good
                My friends eat there
                My parents want me to
                I do not eat the school lunch because I bring my own lunch to school
                I do not eat lunch.

S48.     Have you received information about how to eat healthy and stay fit from anyone?
         Mark all that apply.
                      No
                      Yes, from school (teachers, lessons)
                      Yes, from other students
                      Yes, from family
                      Yes, from coaches
                      Yes, from others.

S49.     Have you had any class lessons about how to eat healthy? Mark all that apply.
                 No
                 Yes, in Science
                 Yes, in PE
                 Yes, in Health
                 Yes, in other classes.

S50.     Have you had any class lessons about how to stay fit? Mark all that apply.
                 No
                 Yes, in Science
                 Yes, in PE
                 Yes, in Health
                 Yes, in other classes.

S51.     How tall are you without your shoes on?
         Write your height in feet and inches. E.g. If you are 4 feet 9 inches tall,
         you would answer the question as follows: 4 Feet 9 Inches

                                   Feet                                  Inches

S52.     How much do you weigh without your shoes on?
         E.g. If you weigh 87 pounds, you would answer the question as follows: 87 lbs.

                                    Lbs
       San Mateo Study 2005-07                                                    Middle School Post Questionnaire
       Year 3 April 2008
                                 Middle School Post Test
Project HEART is a special project that tries to improve students‟ eating and exercise habits.

S53.     Did you hear/see things about Project HEART this year?
                  Yes
                  No
                  Don‟t know

S54.     Did you take part in any Project HEART activities this year?
                  Yes
                  No
                  Don‟t know


The project has conducted various activities on your campus.

Mark if you were aware of any of these activities happening at your school                        Yes       No
S55.     Big banners in lunchrooms                                                                         
S56.     Fitness challenges                                                                                
S57.     Posters and flyers around campus                                                                  
S58.     Improvements to food served in lunchroom                                                          
S59.     Classroom presentations on nutrition & being physically fit                                       
S60.     Special event/carnival/relay race on food and fitness themes                                      
S61.     A play about Fast Food by Westmoor high school students                                           
S62.     Surveys for students and faculty about the school lunch.                                          
S63.     A video about teen eating and shown in classes                                                    
S64.     Communications (Newsletters) to parents to improve the food served at home                        


Mark if you took part in any of these:                                                            Yes       No
S65.     Making posters to hang on campus                                                                  
S66.     Doing „Fitness Challenges‟                                                                        
S67.     Posting nutrition and fitness posters on campus                                                   
S68.     Working on improvements to food served in lunchroom                                               
S69.     Hearing classroom presentations or lessons on nutrition & being physically fit                    
S70.     Attending special event, i.e Activity day, carnival, assembly, relay, on food and
                                                                                                           
         fitness themes
S71.     Viewing the play about eating/exercise presented by Westmoor HS students                          


       San Mateo Study 2005-07                                           Middle School Post Questionnaire
       Year 3 April 2008
                                  Middle School Post Test
S72.     Discussing the Westmoor students play in class                                                        

Mark if you took part in any of these:

                                                                                             Yes           No
S73.     Conducting surveys about what students and faculty want to change in
                                                                                                          
         lunchroom
S74.     Creating an „Activity Book‟ on nutrition and being physically fit                                
S75.     Trying to involve parents to improve the food they serve at home                                 
S76.     Doing other activities about nutrition and being physically fit not mentioned                    


These questions are about you.
                                                                      Yes      Somewhat       A little          No

S77.     I believe eating healthier can improve my health                                                    
         I believe doing about 30 minutes a day of physical
S78.                                                                                                         
         activity would improve my health
S79.     I read labels to see if foods I am eating are healthy                                               
         I am able to make healthy selections at fast food
S80.                                                                                                         
         restaurants
         I have increased the time I spend being physically
S81.                                                                                                         
         active
S82.     I want to be healthier / fitter                                                                     
S83.     I help my friends eat better foods                                                                  
S84.     I influence my family to eat better                                                                 
         I am trying to limit the hours I spend in front of the
S85.                                                                                                         
         screen (TV / computer)




       San Mateo Study 2005-07                                          Middle School Post Questionnaire
       Year 3 April 2008

								
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