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Salem Community Food Assessment Survey
1.
How do you usually get to the supermarket or food store?
Walk
Drive myself
A friend drives me
Bus
Taxi
Bike
Other (please specify)
2.
How long does it typically take to get to the supermarket or food store?
Less than 5 mins
5-10 mins
11-20 mins
21-30 mins
31-45 mins
More than 45 mins
3.
What is the name and location of the store where you buy MOST of your food? (e.g. "Market Basket on Highland Ave.)
4.
What foods do you have the MOST difficulty finding near your home? (Check all that apply)
Fruits and/or vegetables (fresh or frozen)
Lean meats or proteins (beef, poultry, fish, eggs, beans, nuts, etc.)
Whole grains
Dairy products
Foods native to my culture or family tradition
Other (please specify)
5.
How often do you (or a household member) cook or prepare meals from scratch?
Daily
Several times per week
Weekly
Monthly
A few times per year
Never
6.
How often do you eat takeout or fast food?
Daily
Several times per week
Weekly
Monthly
A few times per year
Never
7.
How often do you eat out at non-fast food restaurants?
Daily
Several times per week
Weekly
Monthly
A few times per year
Never
8.
About how many servings of fruits and vegetables do you eat each day? (Note: a serving is about 1/2 cup of chopped fruits and veg, 1 small apple, 1/2 banana, a handful of carrots, or 2 cups raw, leafy greens).
0
1
2
3
4
5
More than 5
9.
If less than 5, what MOST prevents you from eating 5 or more servings of fruits and vegetables each day? (Check all that apply)
They cost too much
Unable to find them in local stores
Personal or family preferences
Not sure how to make them taste good
Preparation time
My schedule
Other (please specify)
10.
Where do you find information on nutrition and healthy eating? (Check all that apply)
Food labels
Family and/or friends
School
Media (TV, books, newspaper, internet, etc.)
Physician or dietitian
Cannot find good information
Other (please specify)
11.
Would you be interested in participating in community nutrition education programs in Salem?
Yes
No
12.
Do you grow any of your own food?
Yes
No
13.
If 'No', are you interested in learning about growing your own food?
Very interested
Fairly interested
Not very interested
Not interested at all
14.
Do you participate in a community garden program? (If yes, skip to question 17.)
Yes
No
15.
If 'No', would you be interested in growing your own food at a community garden in your neighborhood?
Yes
No
16.
Do you shop at the Salem Farmers' Market?
Yes
No
17.
If 'No', why don't you shop at the Salem Farmers' Market?
Unaware of it
Lack of parking
Lack of transportation
Don't like the location
Inconvenient hours or time
Too expensive
Not enough selection
Other (please specify)
18.
Which neighborhood in Salem do you live in?
Derby Street
Willows
Bridge Street Neck
Point
McIntire
North Salem
South Salem
Gallows Hill
Witchcraft Heights
Downtown
Highland Ave.
Salem Common
Other (please specify)
19.
Are you aware of any emergency food providers in Salem, such as food pantries or hot meal providers?
Yes
No
20.
If 'Yes', have you used one in the past year?
Yes
No
21.
Do you or does anyone in your household currently participate in any of the following programs? (Check all that apply)
SNAP/EBT/Food Stamps
WIC (Women, Infants and Children)
Senior coupons
SSI (Supplemental Security Income)
Free or Reduced School Lunch
Salem Summer Meals Program
Other (please specify)
22.
Are you:
Male
Female
23.
What is your race/ethnicity?
African American
White
Hispanic or Latino
Asian
Other (please specify)
24.
In what range does your household income fall?
Less than $10,000
$10,000-14,999
$15,000-24,999
$25,000-34,999
$50,000-74,999
$75,999-99,999
More than $100,000
Don't know
25.
What is your employment status?
Employed
Not employed
Retired
In armed forces
Student
Disability
26.
How many people live in your household? (include yourself)
# of children under 18:
# of adults 18-64:
# of adults 65 and older: