Hello Poder Student:
You are invited to participate in our survey entitled Pilsen Parent/Child Health & Food Behaviors. This survey is being done to find out health and nutrition information of Pilsen community residents. Your responses will help us to design a free nutrition program for you and your family in the near future. In this survey, approximately 200 parents and one of their children between the ages of 6 and 18 will be asked to complete a survey that asks questions about eating behaviors and food availability. In order for us to start a nutrition program in this community for you, it is very important for us to learn about your family, your household, your eating behaviors, your concerns, and the food choices you usually make for yourself and your child. This online survey will take approximately 30 minutes to complete. If you qualify, there are 3 additional surveys to be completed at home and brought back to us at your next class period. When you return your take-home surveys you will receive a free gift!
Your participation in this study is completely voluntary. There are no known risks to you if you participate in this project.
Your survey responses will be kept private and information from this research will be reported only in a large group of responses with NO NAMES or other personal information attached. In order to keep your name private, please remember to record the identification number on the stickers provided and which will be placed on the take-home surveys that you will receive before you go home.
Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
Have you lived in this (Pilsen/Little Village) community or neighborhood for six months or more? If you do not live in the Pilsen or Little Village community or neighborhood, please identify your community or neighborhood. Are you of Hispanic origin? Do any children between the ages of 6-18 years old live in your household? What is the age of this child? What is your relationship to this child? Not including the hours your child is in school, does the child spend most of his or her time with you? (Do you consider yourself the primary care taker of this child?) Do you usually prepare most of the meals and snacks for this child living in your household? If you do not prepare most the meals and snacks for this child, who does? Who usually does the grocery shopping for the household? Please tell us the names of the stores where you buy your family food? How often do YOU grocery shop? What restaurants do you and your family go to most often? How often do you and your family eat out? Who usually does the cooking? What is your preference for speaking? What is your preference for reading? What is your preference for writing? How many people are living in your household? (including yourself) Please tell us what your relationships are to the people that live in your household. Begin with yourself. Type in your responses in the boxes. | Relationships of household members (for example, daughter, son, mother, husband, wife, etc.) | | | Country in which you were born | Number of years living in the United States | Number of years of schooling | |
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What is your current marital status? What is your household's annual income before taxes? In general, what language(s) do you read and speak? What was the language(s) you used as a child? What language(s) do you usually speak at home? In which language(s) do you usually think? In which language(s) do you usually speak with your friends? In what language(s) are the T.V. programs you usually watch? In what language(s) are the radio programs you listen to? In general, what language(s) are the movies, T.V. and radio programs you PREFER to watch and listen to? You prefer going to social gatherings/parties at which people are: The persons you visit or who visit you are: If you could choose your children's friends, would you want them to be: Where was your father born? Where was your mother born? Where was your father's mother born? Where was your father's father born? Where was your mother's mother born? Where was your mother's father born? How many times a week do YOU eat breakfast? How many times per week does YOUR CHILD eat breakfast? How concerned are you about your child eating too much when you are not around him/her? How concerned are you about your child having to diet to maintain a desirable weight? How concerned are you about your child becoming overweight? How concerned are YOU about eating too much? How concerned are you about YOUR having to diet to maintain a desirable weight? How concerned are YOU about becoming overweight? During the past month, how often would you say you have mentioned YOUR CHILD'S WEIGHT to your child? During the past month, how often has your child heard you complain about YOUR OWN WEIGHT? Your height (how tall are you?) (In feet and inches, example: 5'7") Your weight (how much do you weigh?) (In pounds, example: 145 lbs) Child's height (in feet and inches) Child's weight (in pounds) Is this child a boy or a girl? STOP!!! DO NOT HIT CONTINUE!!! Thank you for your time, you have completed the survey. Please RAISE YOUR HAND and an instructor will be over to assist you. |
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