OMB Number 0910-0545
Expiration Date: XX/XX/XXXX
2011 FDA HEALTH AND DIET SURVEY
DIETARY GUIDELINES
DRAFT QUESTIONNAIRE
SCREENER
Hello, I'm ________________ with Synovate. I’m calling on behalf of the United States Food and Drug Administration, the FDA. We’re doing a study about people’s opinions about nutrition and health to help the FDA design better programs to improve the Nation’s health. May I speak to the member of your household who is aged 18 or over and has had the most RECENT birthday? Would that be you?
Yes 1 [GO TO INTRODUCTION.]
No 2 [READ THE FOLLOWING.]
May I speak with a member of the household who is at least 18 years old and has the most recent birthday?
Yes 1 [REINTRODUCE]
No/Not Available 2 [GO TO SMS]
[IF NOT AVAILABLE, ASK FOR THE FIRST NAME OF THE ELIGIBLE RESPONDENT FOR CALL-BACK PURPOSE.]
[REINTRODUCE AS NECESSARY.]
INTRODUCTION
This call may be monitored for quality control purposes. Your answers to this survey are voluntary and will be kept confidential. The survey will take about 10 minutes.
INTERVIEWER: CODE SEX WITHOUT ASKING.
Male ……………….. 1
Female …………….. 2
Not Sure …………… 8
A. DIETARY GUIDELINES FOR AMERICANS
A1. First, let’s talk a little bit about grocery shopping. How important is nutrition to you when you shop for food? Would you say nutrition is very important, somewhat important, somewhat unimportant, or not at all important to you when you shop for food?
Very important ………………………………………. 1
Somewhat important ………………………………… 2
Somewhat unimportant …………………………….. 3
Not at all important ………………………………….. 4
[DON'T READ] Don’t know (DK)/Not sure (NS) … 8
[DON’T READ]Refused (RF) ……………………… 9
A2. Have you looked for nutrition information from any Federal government sources in the past 6 months?
Yes ………………………………… 1
No …………………………………. 2
[DON'T READ] DK/NS …………. 8
[DON’T READ]RF ………………. 9
A3. How easy or difficult would you say it is to get nutrition information from Federal government sources? Would you say it is [READ OPTIONS]?
Very easy,. ………………………….. 1
Somewhat easy,……………………… 2
Somewhat difficult, …….…………… 3
Very difficult, or .………..…………… 4
Don’t you know ? …..………………… 5
[DON’T READ]RF ………………… 9
A4. How reliable would you say nutrition information provided by the Federal government is? Would you say it is [READ OPTIONS] ?
Very reliable, …………………………………1
Somewhat reliable, ……………………………2
Somewhat unreliable, …………………………3
Not reliable at all, or …….……………………4
Don’t you know? …….….……………………5
[DON’T READ]RF …………………………9
A5. How often do you use Federal government Web sites to look for nutrition information? Would you say you do this…[READ OPTIONS. ACCEPT ONE]
A few times a week………………….. 1
A few times a month ….…………….. 2
Once a month, ……..………………… 3
Less often than once a month, or ……. 4
Never ………………………….…….. 5
[DON'T READ] DK/NS …………… 8
[DON’T READ]RF ………………… 9
A6. Have you heard anything about the following information on diet and health? Have you heard anything about… yes or no? What about …
Yes . ………………………. 1
No…………………………. 2
[DON'T READ] DK/NS … 8
[DON’T READ]RF ……… 9
The Five-A-Day Program
The Dietary Guidelines for Americans
MyPyramid
Fruits and Veggies—More Matters
[IF “DIETARY GUIDELINES” = ”YES,” GO TO A7. IF “DIETARY GUIDELINES” = ”NO/DK/NS/RF,” SKIP TO A10.]
A7. How familiar would you say you are with the Dietary Guidelines for Americans? Would you say you are… [READ OPTIONS. SELECT ONE]
Very familiar……………………………………………… 1
Somewhat familiar …………............…………………...... 2
Not very familiar, or ……………………………………… 3
You only know the name, but not the actual guidelines….. 4
[DON'T READ] DK/NS ……………….……………….. 8
[DON’T READ]RF ………………………………….…. 9
A8. In the past 6 months, have you heard any news about the Dietary Guidelines for Americans?
Yes ………………………. 1
No …………………………. 2 [SKIP TO A10]
[DON'T READ] DK/NS ……8 [SKIP TO A10]
[DON’T READ]RF ……… 9 [SKIP TO A10]
A9. Now, I am going to read a list of places that people may have heard or read about Dietary Guidelines for Americans. First, have you yourself heard or read about Dietary Guidelines for Americans [RANDOM START; KEEP ITEMS G, H, and I TOGETHER AND IN THAT ORDER.], yes or no? Have you heard about Dietary Guidelines for Americans [READ SECOND ITEM], [REPEAT “Have you heard about Dietary Guidelines for Americans” FOR OTHER ITEMS WHEN NECESSARY.]? What about ….. ?
Yes ………………………. 1
No …………………………. 2
[DON'T READ] DK/NS … . 8
[DON’T READ]RF ……… 9
On the radio
On television
From a government Web site
From a non-government Web site
In a magazine
In a newspaper
From a doctor
From a dietician or nutritionist
From another health care provider
From family
From friends
At work or from co-workers
In supermarket brochures or pamphlets
A10. Next, I am going to read some statements about health, food, and exercise. As I read each statement, please tell me how much you agree or disagree with it. The first statement is… “[RANDOM START]…” Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with it? …The next statement is “…” [REPEAT RESPONSE OPTIONS WHEN NECESSARY.]…The next statement is…
Strongly agree ……………………………. 1
Somewhat agree …………………………... 2
Somewhat disagree ………………………. 3
Strongly disagree …………………………. 4
[DON'T READ] DK/NS ……………….… 8
[DON’T READ]RF …………………….… 9
Having healthy eating habits is very important to me.
I am actively trying to eat a healthy diet.
I am confident that I know how to choose healthy foods.
I am confident that I know how much physical activity I should be doing.
I am making healthier food choices now than I was 6 months ago
I am more physically active now than I was 6 months ago
The amount of food you should eat depends on how many calories you burn each day
I am actively trying to balance the amount of food I eat with the amount of exercise I get
A11. Next, I would like to ask you how many days per week you do a variety of things. If you don’t usually do these things at least once a week, please say zero. Now, thinking of a typical seven-day week, how many days per week do you [RANDOM START] And how many days per week do you ….? What about …
[IF RESPONDENT SAYS SOMETHING LIKE “I DON’T EAT FISH AT ALL” OR “I NEVER KEEP TRACK OF CALORIES,” ACCEPT THE ANSWER WITHOUT PROBING.]
[IF RESPONDENT GIVES A RANGE, ASK FOR ONE ANSWER. FOR EXAMPLE IF RESPONDENT SAYS “2 TO 3,” ASK IS IT 2 OR 3?]
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON’T READ] I don’t eat it/
eat these things/do it at all ………. 9
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
Keep track of the calories you eat
Get at least 30 minutes of exercise or physical activity
Eat at least five servings of fruits or vegetables
Eat whole grain breads or cereals
Have 3 servings of milk, yogurt, or cheese
Eat fish
Drink sugar-sweetened beverages
Eat beans or peas
A11a. Next, I am going to mention six different foods. As I mention each one, please tell me whether you would say it is a whole grain food? First, is [RANDOM START] a whole grain food, yes or no? Is [SECOND ITEM] a whole grain food, yes or no? What about ….? [REPEAT “Is [ITEM] a whole grain food, yes or no” WHEN NECESSARY.]
Yes ……………………………………………….… 1
No …………………………………………………... 2
[DON’T READ] I don’t know what whole grain is ….. 3
[DON’T READ] I don’t know what the food is ……… 4
[DON'T READ] DK/NS …………………………… 8
[DON'T READ] RF ………………………………. 9
Rye bread
oatmeal
popcorn
corn flakes
French bread
whole wheat bread
A12. Now think about the foods you eat. Would you say you always, sometimes, rarely, or never [RANDOM START]
Always ……………………...................... 1
Sometimes …………………...................... 2
Rarely ………………….…...................... 3
Never …………………….………………. 4
[DON’T READ] I don’t eat
meat (or chicken, or foods containing salt, or cheese) at all ………….5
[DON'T READ] DK/NS ….……………… 8
[DON’T READ]RF ……….……………… 9
Choose lean meat over fatty meat
Choose chicken without skin over chicken with the skin on
Choose foods with reduced salt content over foods with regular salt content
Choose reduced-fat cheese over regular cheese
A13. When you drink milk, which of the four kinds of milk do you drink most often, fat-free, one percent, two percent, or whole milk?
Fat-free …………………………………………….. 1
1% ………………………………………………… 2
2% ………………………………………………… 3
Whole milk …………………………….. 4
[DON’T READ] I don't drink milk at all …………. 5
[DON'T READ] DK/NS ….……………….……… 8
[DON’T READ]RF ……….…………………….… 9
B. SPECIAL DIET AND WEIGHT CONTROL
B1. Have you tried to limit any of the following things in your diet in the past 30 days? Have you tried to limit the amount of [READ AND ROTATE LIST.] in your diet, yes or no? …. What about ….? [REPEAT “YES OR NO” WHEN NECESSARY]
Yes …………………………………………… 1
No ……………………………………………. 2
[DON’T READ] I don’t know what it is ………. 7
[DON'T READ] DK/NS …………………….. 8
[DON'T READ] RF ………………………… 9
saturated fat
trans fat or trans fatty acid
calories
cholesterol
carbohydrates
sodium
sugar
B3. How do you describe your health? In general, would you say your health is…? [READ OPTIONS. ACCEPT ONE]
Excellent ………………..…… 5
Very good ………………..…. 4
Good ………………..……..... 3
Fair, or ……………………… 2
Poor …………………….….... 1
[DON’T READ] DK/NS …… 8
[DON’T READ] RF ………… 9
B4. Do you consider yourself to be overweight, underweight, or about the right weight? [IF RESPONDENT MENTIONS OTHERS’ OPINIONS, E.G., MY DOCTOR SAYS I’M OVERWEIGHT, READ: “What we really want to know is how YOU yourself think about your weight.”]
Overweight ……………………………… 1
Underweight ……………………………. 2 [SKIP TO C1]
About the right weight …………………... 3 [SKIP TO C1]
[DON’T READ] DK/NS ……………… 8 [SKIP TO C1]
[DON’T READ] RF …………………… 9 [SKIP TO C1]
IF B4 = “OVERWEIGHT,” GO TO B6 (ARE YOU CURRENTLY TRYING TO LOSE WEIGHT?)
(B5 is not used)
B6. Are you currently trying to lose weight?
Yes……………………………….. 1
No……………………………..…. 2
[DON'T READ] DK/NS ………… 8
[DON’T READ]RF ……………… 9
[All respondents]
C. DEMOGRAPHICS AND HEALTH STATUS
Finally, I have some questions for statistical purposes.
C1. Are there any telephone numbers in addition to (the telephone number being called) in your home that you receive calls on? Please do not include cellular phone numbers or numbers used only for fax or computer.
Yes ……………………………………… 1
No ………………………………………. 2 [SKIP TO C3]
[DON’T READ] RF …………………… 8 [SKIP TO C3]
[DON’T READ] DK/NS ………………. 9 [SKIP TO C3]
C2. Is this/Are these numbers (s) for …
Home use ……………………………….. 1
Business and home use, or ………………. 2
Business use only ………………………. 3
[DON’T READ] DK/NS ……………….. 8
[DON’T READ] RF …………………….. 9
C3. How many adults, age 18 years or older, including yourself, now live in your household?
NUMBER: ____________ (RANGE: 1-15)
[DON’T READ] DK/NS ……………. 88
[DON’T READ] RF …………………. 99
C4 And how many children under 18 years of age, including infants and newborns, live in your household?
NUMBER: ____________ (RANGE: 0-15)
[DON’T READ] DK/NS ……………. 88
[DON’T READ] RF …………………. 99
C5. What is the highest grade or level of school you have completed or the highest degree you have received? [DO NOT READ LIST.]
0-11 years/grades ………………………………………… 1
12 years/high school graduate/GED ……………………….. 2
1-3 years of college/associate degree ….…………………… 3
4 years of college/college graduate ……………...................... 4
postgraduate/masters/doctorate/law degree/MD ………….... 5
[DON’T READ] DK/NS ………………………………… 8
[DON’T READ] RF ………………………………………. 9
C6. Are you of Hispanic or Latino origin?
Yes …………………………………… 1
No …………………………………… 2
[DON’T READ] DK/NS …………….. 8
[DON’T READ] RF ………………… 9
C7. What is your race? I am going to read you several categories of race. You may choose as many as they apply. Are you…. [ACCEPT MULTIPLE ANSWERS.]
White ………………………………………………... 1
Black or African American ………………………….. 2
Asian ………………………………………………… 3
Native Hawaiian or other Pacific Islander …………… 4
American Indian or Alaskan Native …………………. 5
[DON’T READ] Hispanic …………………………… 6
[DON’T READ] Other ………………………………. 7
[DON’T READ] DK/NS ……………………………. 8
[DON’T READ] RF ………………………………… 9
C8. What year were you born?
19 ________ (RANGE: 1900-1993)
[DON’T READ] DK/NS …………….. 8
[DON’T READ] RF …………………. 9
[RESPONDENT AGE = 2011 – C8.]
C9. The next two questions may seem a bit personal, but we need this information because our research is about nutrition and health. How tall are you without shoes? [ROUND UP TO THE NEXT WHOLE NUMBER. FOR EXAMPLE, 3.5 INCHES SHOULD BE CODED AS 4 INCHES.]
___________ feet and __________ inches
OR
___________ meter(s) and/or ___________ centimeters
DK/NS …………………………… 888
RF ………………………………… 999
C10. How much do you weigh without shoes? [ROUND UP TO THE NEXT WHOLE NUMBER. FOR EXAMPLE, 122.5 POUNDS SHOULD BE CODED AS 123 POUNDS.]
___________ pounds
OR
___________ kilograms
DK/NS …………………………… 888
RF ………………………………… 999
(C11 omitted)
C12. Have you ever been told by a doctor or other healthcare professional that you have any of the following health conditions? I don’t need to know which condition, just whether you have ANY of them. [READ: “high blood pressure, diabetes, high cholesterol, heart disease, obesity, overweight, or cancer.”]
YES ……………........................... 1 [SKIP TO C14 OR GENDER]
NO ……………………………... 2 [GO TO D13]
[DON’T READ] DK/NS ……….. 8 [GO TO D13]
[DON’T READ] RF …………… 9 [GO TO D13]
C13. Would you expect yourself to be at risk in the next five years for any of the health conditions I just read? [IF NECESSARY, REPEAT THE LIST OF CONDITIONS.]
YES ……………........................... 1
NO ……………………………... 2
[DON’T READ] DK/NS ……….. 8
[DON’T READ] RF …………… 9
GENDER. [INTERVIEWER: IF SEX AT INTRODUCTION IS ''NOT SURE,' ASK: “ The research requires us to ask everyone this question: are you a male or female?”]
Male …………………….. 1
Female …………………… 2
RF ……….………………. 9
C14. I am going to read you a list of categories of income. Please stop me when I read the category that includes your total household income before taxes for year 2003.
Less than twenty-five thousand dollars …………….…………………..… 1
From twenty-five to less than fifty thousand dollars ……………………... 2
From fifty to less than seventy-five thousand dollars ……………………. 3
From seventy-five to less than one-hundred thousand dollars ……..……... 4
One hundred thousand dollars or more ………………………………….. 5
[DON’T READ] DK/NS …………………………………………………. 8
[DON’T READ] RF ……………………………………………................. 9
[READ: THOSE ARE ALL THE QUESTIONS I HAVE. THANK YOU FOR YOUR TIME AND COOPERATION. I’D LIKE YOU TO KNOW THAT YOU HAVE MADE AN IMPORTANT CONTRIBUTION TO OUR STUDY.]
[IF THE RESPONDENT ASKED ABOUT WHERE TO GET INFORMATION ABOUT THE TOPICS DISCUSSED IN THE SURVEY, SAY “I AM NOT AN EXPERT ON THESE TOPICS AND I DON’T HAVE THE INFORMATION. BUT YOU CAN CALL 1-888-723-3366 OR VISIT WWW.HEALTHFINDER.GOV.]
X1. [INTERVIEWER: Did the respondent ask for additional information?]
YES …………. 1
NO ………….. 2
Public Disclosure Burden Statement
Public reporting burden for this collection of information is estimated to average 1.2 minutes per response for the screener and 13 minutes per response for the survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to:
Food and Drug Administration
Center for Food Safety and Applied Nutrition
5100 Paint Branch Parkway, HFS-024
College Park, Maryland 20740
| File Type | application/msword |
| File Title | FDA Health and Diet Survey: Dietary Guidelines Supplement |
| Author | CDOBDAY |
| Last Modified By | DPresley |
| File Modified | 2011-05-26 |
| File Created | 2011-05-26 |