Download:
pdf |
pdfForm Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 1 Evaluation Form
Your feedback is important! Please share your opinions about Session 1 of the BodyWorks program by filling out this survey.
I. Please rate each Session 1 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
understand was this activity?
2. How interested were you in this
activity?
3. How much new information did
you learn from this activity?
a. Introduction to BodyWorks—discussion
and PowerPoint presentation
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Discussion on the benefits and barriers
to change
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Activities
Discussion on behavior change
d. Activity on how to set goals
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Describe the goals of the kit overall, and the specific components that target family members
Understand the goals and expectations of the nine follow-up sessions
Participate in creating a comfortable and trusting tone for the group
Identify ground rules for discussions
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 2 Evaluation Form
Your feedback is important! Please share your opinions about Session 2 of the BodyWorks program by filling out this survey.
I. Please rate each Session 2 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Discussion on how participants
presented BodyWorks to their families
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Discussion on healthy weight and the
risks of overweight
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Interested
Very interested
No new information
Some new information
A lot of new information
Discussion on eating and emotions
d. Demonstration on how to use the
BodyWorks journals
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Understand my role as a parent in promoting healthy lifestyles for my family
Define what a healthy weight is for teens and describe the health risks of being overweight
Identify the risks of osteoporosis for my daughter(s) and describe how I can manage my own risk
Identify practical alternatives to eating to deal with negative emotions such as sadness, depression, stress, and
boredom, particularly for teen girls
Use the “Family Food and Fitness Journal” and help my daughter(s) use the “Best Journal Ever!” for girls
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 3 Evaluation Form
Your feedback is important! Please share your opinions about Session 3 of the BodyWorks program by filling out this survey.
I. Please rate each Session 3 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Review of first week using the daily
journals
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Healthy smoothie demonstration
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Discussion on the basics of healthy
eating for children, teens, and adults
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Use the BodyWorks journals every day
Assess the information in my journals in order to set goals
Describe the components of a healthy, balanced diet for children, teens, and adults
List the nutrients girls need to grow strong and healthy
Describe the importance of breakfast for girls’ bone and overall health
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 4 Evaluation Form
Your feedback is important! Please share your opinions about Session 4 of the BodyWorks program by filling out this survey.
I. Please rate each Session 4 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Serving size activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Review of serving size information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Review of facts about fat
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
d.
Discussion on making healthy lunch
choices
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
e.
Discussion on making healthy fast food
and beverage choices
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Identify how much food equals a serving size
Identify the different types of fat
Know how to make healthy lunch food choices for myself and my family, including foods that are good
sources of calcium and vitamin D
Know how to choose healthier foods and drinks at fast food restaurants
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 5 Evaluation Form
Your feedback is important! Please share your opinions about Session 5 of the BodyWorks program by filling out this survey.
I. Please rate each Session 5 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Discussion on physical activity barriers
and benefits
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Discussion on types of physical activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Limiting screen time--discussion and
case study
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a. Understand barriers to physical activity and how to overcome them
b. Describe the physical activity recommendations for adolescents and adults
c. Identify which physical activities strengthen bones, and why these types of activities are important to their
daughter’s bone health
d. Do stretching exercises
e. Limit my children’s screen time
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 6 Evaluation Form
Your feedback is important! Please share your opinions about Session 6 of the BodyWorks program by filling out this survey.
I. Please rate each Session 6 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Activity to set family goals
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Activity to learn how to use the weekly
planner magnet
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Discussion on involving the family in
planning, shopping, and cooking
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Set family goals to eat healthier foods and become more physically active
Use the weekly planner magnet to plan healthy meals
Make shopping lists based on the meals and snacks planned for the week
Encourage my daughter(s) to help plan meals, shop, and cook
Use the daily journal
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 7 Evaluation Form
Your feedback is important! Please share your opinions about Session 7 of the BodyWorks program by filling out this survey.
I. Please rate each Session 7 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. “Let’s Shop, Cook, and Eat Together”
DVD—viewing and discussion
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Review of how to read nutrition labels
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a. Use the BodyBasics tools to shop for healthy foods
b. Read and understand nutrition labels on food packaging
c. Make informed, healthy food choices for my family
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 8 Evaluation Form
Your feedback is important! Please share your opinions about Session 8 of the BodyWorks program by filling out this survey.
I. Please rate each Session 8 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a. Viewing of the “Let’s Shop, Cook, and
Eat Together” DVD
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b. Discussion on DVD content about
cooking healthy meals and the
BodyWorks recipe book
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
Discussion on DVD and BodyBasics
content about the importance of eating
together as a family
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Use the BodyWorks recipe book to prepare healthy foods
Locate resources for other healthy recipes
Prepare foods in healthier ways, including preparing foods with calcium and vitamin D
List the benefits of eating meals together as a family and overcoming barriers to doing this
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 9 Evaluation Form
Your feedback is important! Please share your opinions about Session 9 of the BodyWorks program by filling out this survey.
I. Please rate each Session 9 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Environmental checklist activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Goal setting for environmental issues
activity
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
Identify barriers to being physically activity and healthy eating at home, in the community, and in schools
Come up with workable strategies to address barriers to physical activity and healthy eating
Become an activist at school and in the community to improve environmental issues related to physical
activity and healthy eating
Identify other resources that support healthy environments and foster physical activity and healthy eating for
girls
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
Session Date: _______________
Parent BodyWorks Session 10 Evaluation Form
Your feedback is important! Please share your opinions about Session 10 of the BodyWorks program by filling out this survey.
I. Please rate each Session 10 activity according to: (1) how clear and easy to understand it was; (2) how interested you were in it; and (3) how much new
information you learned from it. For each activity, check one box per question.
1. How clear and easy to
2. How interested were you in this
3. How much new information did
Activities
understand was this activity?
activity?
you learn from this activity?
a.
Media literacy quiz
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
b.
Activity analyzing a tobacco ad
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
c.
Handout and discussion on types of
advertising techniques
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
d.
Activity analyzing a magazine ad
Not at all clear
Somewhat clear
Very clear
Not at all interested
Somewhat interested
Very interested
No new information
Some new information
A lot of new information
II. Please rate how confident you are that you can do the following tasks. Check one answer for each task.
a.
b.
c.
d.
e.
Describe how the media affects the body image of girls and women
Describe how ads encourage people to buy unhealthy foods and live unhealthy lifestyles
Examine the ways that ads influence what people buy
Identify ways my family can maintain the healthy habits they have already adopted
List the most important actions that I have taken during BodyWorks for myself and my family to eat healthy
foods and be physically active on a regular basis
Not Confident
at all
Somewhat
confident
Very
Confident
III. Please tell us what worked well and what needs to be improved.
a. What worked well?___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
b. What should be improved?____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/pdf |
| Author | Dana Martin Scott |
| File Modified | 2009-01-29 |
| File Created | 2009-01-29 |