Form 0917-0036 Sugar Shockers Health Campaign Survey, Catawba Service U

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Sugar Shockers Health Campaign Survey

Education and Community Outreach (ECO) Team

Catawba Service Unit

Date: ________________________________________

Age: _________________________________________

Tribe: Catawba None Other: __________

Gender: Male Female

1. How often do you drink regular soda or pop that contains sugar, such as Coke, Pepsi, or Sprite?
   Do NOT include diet soda.

____ per day

____ per week

____ per month

2. How often do you drink sugar-sweetened fruit drinks (such as Kool-aid or lemonade), sweet tea, and sports or energy drinks (such as Gatorade and Red Bull)? Do NOT include diet soda, sugar free drinks, or 100% juice.

____ per day

____ per week

____ per month

3. During the past 7 days, how many times did you drink a can, bottle or glass of regular soda or pop that contains sugar? Do NOT include diet soda.

• None

• 1-2 times

• 3-4 times

• 5 or more

4. During the past 7 days, how many times did you drink a can, bottle or glass of sugar-sweetened fruit drinks, sweet tea, and sports or energy drinks? Do NOT include diet soda, sugar free drinks, or 100% juice.

• None

• 1-2 times

• 3-4 times

• 5 or more

5. Why do you drink regular sodas or sugar-sweetened drinks? (check all that apply)

• Taste

• Caffeine

• Refreshment

• Brand Loyalty

• I do not drink regular sodas or sugar-sweetened drinks

6. Are you willing to drink water as an alternative if regular sodas or sugar-sweetened beverages are not available?

• Yes

• No

If no, why not? ____________________________

7. In the past 3 months, have you changed how many regular sodas or sugar-sweetened beverages you drink each day?

   • Cut down

   • Increased

   • No change

   • I do not drink regular sodas or sugar-sweetened beverages

8. In the last 3 months, have you considered cutting down the number of regular sodas or sugar-sweetened beverages you drink each day?

   • Yes

   • No

   • I do not drink regular sodas or sugar-sweetened beverages

9. Do you believe that drinking regular soda or sugar-sweetened beverages can affect your health?

• Yes

• No

• I don’t know

If yes, how can it affect your health? __________ ________________________________________

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 0917-0036.  The time required to complete this information collection is estimated to average five 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 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.