3 Dietary Behavior

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 03 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

OMB#: 0925-XXXX

Exp. XX/XXXX

HCHS/SOL Dietary Behavior Questionnaire

ID NUMBER:

FORM CODE: DBE VERSION: A 6/25/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

1. Of Hispanic/Latino and American food, do you usually eat…? (Mark only one)

Mainly Hispanic/Latino foods 1

Mostly Hispanic/Latino foods and some American food 2

Equal amounts of both Hispanic/Latino and American foods 3

Mostly American foods and some Hispanic/Latino foods 4

Mainly American foods 5

2. How often do you or your family usually go out to eat at or bring home ready-to-eat foods from…?

Less than 1-2 3-4 5 or more

once a times times times per

Never week per week per week week

a. Relatives’ or Friends’ homes 1 2 3 4 5

b. Fast food restaurants

(including Latino and Chinese food) 1 2 3 4 5

c. Sit down restaurants (with table service) 1 2 3 4 5

d. Buffet restaurants (including Chinese buffet) 1 2 3 4 5

e. Pick-up-and-take-home restaurants 1 2 3 4 5

f. Grocery stores (hot or cold ready-to-eat

food from store) 1 2 3 4 5

g. Cafeterias (school or work) 1 2 3 4 5

h. Vending machines 1 2 3 4 5

i. On-street vendors (including trucks,

carts, and wagons) 1 2 3 4 5

j. Other (for example quick marts,

bakeries, etc.) 1 2 3 4 5

Dietary Behavior Form (DBE) Page 1 of 1