Spring 2019


This survey is about health behavior. The information you give will be used to improve health education for young people like yourself. Please be sure to read every question.

You do not need to write your name on this survey. The answers you give will be kept private. Please answer the questions based on what you really do. The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. 

Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.

Thank you very much for your help!

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* 1. How old are you?

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* 2. What is your sex?

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* 3. In what grade are you?

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* 4. Are you Hispanic or Latino?

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* 5. What is your race? (Select one or more responses.)

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* 6. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)

The next 6 questions ask about food you ate or drank during the past 7 days. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.

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* 7. During the past 7 days, how many times did you eat green salad?

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* 8. During the past 7 days, how many times did you eat potatoes? (Do not count french fries, fried potatoes, or potato chips.)

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* 9. During the past 7 days, how many times did you eat carrots?

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* 10. During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)

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* 11. During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.)

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* 12. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)

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* 13. Do you have any of the following health conditions? (select all that apply)

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* 14. Have you ever visited the school nurse for any of the conditions you marked in the previous question?

This is the end of the survey. Thank you very much for your help!

This survey is being done as part of the “Improving Student Health and Academic Achievement through Nutrition, Physical Activity and the Management of Chronic Conditions in Schools” grant, which is funding from NDE through CDC-RFA-DP18-1801.
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