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Survey Templates Surveys Prelim

Prelim

Sample Survey


Hello:

You are invited to participate in a preliminary survey for a future adolescent nutrition and obesity-related study. In this preliminary trial, a small group of individuals aged 15-17 will be asked to complete a short open-ended questionairre that will be used to construct a similar, large-scale nutritional knowledge survey that will be administered in the near future. It will take approximately 10-15 minutes to complete the questionnaire.


Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.


Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact the principal investigator by email at [email protected].


Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.




Federalwide Assurance #FWA00003913 was approved for Rutgers, The State University of New Jersey, by the Office for Human Research Protections (OHRP) on December 31, 2002 and is valid until August 20, 2006.


Additional Contact Information:

Dr. Michael E. Breton

Associate Vice President for Research and Sponsored Programs

Rutgers, The State University of New Jersey

ASB III, 3 Rutgers Plaza

New Brunswick, NJ 08901

Phone: 732/932-0150 x3017

Fax: 732/932-0145

[email protected]

What is your gender?
What is your age?
What is your race or ethnicity?
Do you participate regularly in physical activity?
On a scale from 1-10, how would you rate your overall health? (1 = Worst, 10 = Best)
What constitutes a "healthy" food?
Please provide a few examples of "healthy" foods.
What constitutes an "unhealthy" food?
Please provide a few examples of "unhealthy" foods.
How often do you eat these "unhealthy" foods?
Do you try to refrain from eating these "unhealthy" foods?

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