Form Approved
OMB No. 0990- NEW
Exp. Date XX/XX/2012
Baseline Let’s Move! Cities, Towns and Counties Participant Survey
This survey is being conducted by the U.S. Department of Health and Human Services. The information gathered from this survey will be used to identify and adequately assess who is participating in Let’s Move! Cities, Towns and Counties (LMCTC) and which activities and strategies they have agreed to implement. The information will also be used to track progress over time in achieving LMCTC goals and identifying geographic areas for outreach and technical assistance needs. Information collected through the survey will also assist in disseminating promising practices to ultimately increase the number and diversity of individuals, organizations, and groups that are addressing the LMCTC activities and strategies within communities. Promising practices may be publicly highlighted and celebrated in public forums, posted on the the Let’s Move! Website or annual reports. In addition, the organization information as well as the name of a contact person may be made available on the Let’s Move! Website for replication purposes.
If you have any questions about the study, please contact [RWJF Project Coordinator].
Your cooperation is very much appreciated.
Part I Demographic Information
Contact for Goal Tracking Information:
Name
Title
Organization
Address1
Address 2
City/Town
State
Zip Code
Email Address
Telephone 1
Telephone 2
What type of municipality are you?
City, Town or County
Have you signed up to be a Let’s Move! City, Town or County previously?
Yes
No
In what HHS Region are you located? See this link for the HHS Regions: http://www.hhs.gov/about/regionmap.html
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
What is the official title of the Elected Official(s) leading effort?
Title 1
Title 2
Title 3
What is the primary elected official’s mailing address?
Address 1
Address2
City/Town
County
State
Zip
What is the primary elected official’s telephone number?
What is the primary elected official’s email address?
If there are additional points of contact that you would like to have receive information on Let's Move, please enter his/her information:
Name
Email Address
Phone Number
Address 1
Address2
City/Town
County
State
Zip
If you have appointed a Lets Move! Community Leader in your community and want this individual to receive the same updates and information as you, please include their name and contact information in the space provided.
Your City's Let's Move! Community Leader's Name:
Email Address
Phone Number
Address 1
Address2
City/Town
County
State
Zip
Will you establish a Let’s Move! Task Force or designate a staff member to participate in an existing Task Force or Work group?
Yes
No, if no why not?
Part II Program Information:
This section will go through a series of questions to ascertain which activities and strategies you will implement through Let’s Move! Cities, Towns and Counties (LMCTC). To be a sustainable LMCTC, a community must reach all five goals. Through this survey and technical assistance, Let’s Move! has provided examples of activities that can assist a community in achieving each of the goals.
Pillar 1, Goal: Increase the number of child care programs incorporating best practices in nutrition, physical activity, and screen time.
Do you commit to the goal of raising the importance of and increasing the number of child care programs incorporating best practices in nutrition, physical activity, and screen time?
Yes
No, if no skip to Pillar 2
Please indicate which activities you’re initiating (check all that apply):
Conduct a Nutrition and Physical Activity Self Assessment for Child Care (NAP SACC) programs.
Conduct a self assessment of child care programs
Assist child care programs with registering to participate in Let’s Move! Child Care
Register municipally-run child care programs to participate in Let’s Move! Child Care (http://healthykidshealthyfuture.org/welcome.html)
Determine if you have authority to set standards that exceed minimum licensing requirements in key areas around obesity prevention
If authority exists, propose standards in key areas around obesity prevention that exceed minimum licensing requirements
If authority exists, enact standards in key areas around obesity prevention that exceed minimum licensing requirements
Recognize child care programs that have successfully incorporated best practices in nutrition, physical activity, and screen time
Other please specify________________________
Pillar 2, Goal: Increase promotion of My Plate information prominently displayed in city and municipal venues where food is offered or sold.
Are you familiar with USDA’s My Plate?
Yes
No, if no go here for more information: http://www.choosemyplate.gov/
Do you currently display My Plate in your city and municipal venues where food is offered or sold?
Yes, if yes approximately how many or what percentage of city and municipal venues display My Plate where food is offered or sold? In how many communities?
No, if no why not? (check all that apply)
Not familiar with my plate
Already have my pyramid displayed
No resources
Other (please explain)____________
Do you commit to the goal of increasing the promotion of My Plate information prominently displayed in city and municipal venues where food is offered or sold?
Yes, if yes how many or what percentage of venues do you estimate you will promote My Plate within a year? And in how many communities?
No, if no why not?
Not familiar with my plate
Already have my pyramid displayed
No resources
Other (please explain)____________
Are you a Community Partner with USDA for Choose My Plate?
Yes, if yes please give the best way to contact you
No, if no go here for more information: http://www.choosemyplate.gov/partnering-program/community-partners.html
Pillar 3, Goal: Increase the number of schools and students participating in the school breakfast and lunch programs
Do you commit to the goal of increasing the number of schools and/or students participating in the school breakfast and lunch programs?
Yes
No, if no skip to Pillar 4
How many schools are in your jurisdiction?
How many of those schools are currently not participating in the school breakfast program?
How many of those schools are currently not participating in the school lunch program?
How many students are in your jurisdiction?
How many of those students are currently participating in the school breakfast program?
How many of those students are currently participating in the school lunch program? Please indicate which activities you will complete to support schools in increasing their participation in the school breakfast and lunch programs (check all that apply):
Publicly express strong support for these programs to school authorities.
Bring together community partners from the public and private sector to work on a strategy to increase participation.
Sharing the message of the importance of federally-funded school meals in addressing children’s nutritional needs with the media.
Requiring city health and human services staff to conduct community outreach to raise awareness about availability and eligibility for these programs. Other, please specify_________________________
Within a year, how many schools do you estimate will have school breakfast programs? How many schools do you estimate will have school lunch programs? And in how many communities?
Within a year, how many students do you estimate will participate in school breakfast programs? How many students do you estimate will participate in school lunch programs? And in how many communities?
Pillar 4, Goal: Adopt healthy and sustainable food service guidelines for municipal spaces that serve food
Are you familiar with using food service guidelines to promote health and sustainability?
Yes
No, if no go here for more information and a sample template: http://www.cdc.gov/chronicdisease/resources/guidelines/food-service-guidelines.htm
Do you commit to the goal of implementing healthy and sustainable food service guidelines for municipal spaces that serve food?
Yes
No, if no skip to Goal 5
Does your jurisdiction already have food service guidelines that work to align food service offering with the Dietary Guidelines for Americans?
Yes, if yes how many or what percentage of cafeterias and vending follow such food guidelines? How many communities are affected by those guidelines?
No, if no and want more information go here: http://health.gov/dietaryguidelines/2010.asp
Please indicate which activities you will initiate to adopt healthy and sustainable food service guidelines (check all that apply):
Establish a food policy council
Participate in a food policy council
Review existing food service guidelines
Create or adapt model healthy and sustainable food service guidelines
Issue a written policy for public service venues/government agencies
Number or percentage of settings/facilities covered________
Direct that food service guidelines be incorporated into contracting languages for bids for food service contracts.
Designate a local government official to lead a guidelines workgroup to strategically implement and evaluate healthy and sustainable food service guidelines across venues
Other, please specify___________________
Pillar 5, Goal: Increase access to play in neighborhoods and schools by mapping local playspaces, completing a needs assessment, and developing and implementing at least three best practices.
Do you commit to the goal of increasing access to play in neighborhoods and communities by mapping local playspaces, completing a needs assessment, and developing and implementing at least three best practices?
Yes
No, if no skip to end
Are you familiar with KaBOOM!’s Playful Cities program?
Yes,
No, if no go here: http://kaboom.org/take_action/playful_city_usa
Will you apply to be a KaBOOM! Playful City 2012?
Yes
No, if no why?
Not familiar with KaBOOM!’s Playful Cities program
Already applied to be a KaBOOM!’s Playful City
No resources
Other (please explain)____________
Will you apply to be a KaBOOM! Playful City 2013?
Yes
No, if not why?
Not familiar with KaBOOM!’s Playful Cities program
No resources
Other (please explain)____________
Will you map the play spaces in your community?
Yes
No, if not why?
Not familiar with how to map play spaces
Play spaces are already adequately mapped
No resources
Other (please explain)____________
Will you assess the need for play spaces in your community?
Yes
No, if no why?
Not familiar with how to conduct such a needs assessment
Recently conducted a need assess around need for play spaces
No resources
Other (please explain)
Will you implement at least three best practices for increasing access to play?
Yes
No, if not why?
Please indicate which best practices you will initiate:
Joint use agreements with schools
Recess policy in schools
Community builds and spruces with schools
Joint use agreements with neighborhoods
Community builds and spruces in neighborhoods
Housing development ordinance
Inclusive play spaces
Play Day
Summer activity programs
Traveling playgrounds
Mobile technology
Other (please specify)_________________
Thank you for your participation in this survey
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. The current OMB control number for information collected through this application process is 09990-NEW and the expiration date is X/XX/2012. Public reporting burden for this collection is estimated to average 15 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HHS OS Reports Clearance Office, 200 Independence Ave SW, 336E, Washington, DC 20201.
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| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |