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* 1. In which county do you live?

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* 2. Do you have children in your household between the ages of (check all that apply):

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* 3. How do you pay for your grocery bill? Check all that apply.

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* 4. Does your doctor/clinician discuss growth charts or Body Mass Index (BMI) with you in relation to your child's development at each "well-child" visit?

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* 5. Have you ever asked your child's doctor about your child's weight?

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* 6. Does your doctor’s office give you handouts or referrals for increasing your child’s physical activity or improving what your child eats?

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* 7. Where does your child receive well-child visits?

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* 8. How much time does your child spend in physically active play each day outside of school?

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* 9. Please indicate how available each of the following is to your family.

  Not available Less available Somewhat available More available Very available
Information about eating better and places for your child to play
Places for your child to play outside
Fresh produce (fruits and/or vegetables) near your home

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* 10. Have you visited a school playground outside of school hours with your child?

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* 11. In the last year, did your child participate in any of the following after school programs?

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* 12. How many servings of the following does your child consume on the average day?

  0 1 2 3 4 5+
Fruits (serving size: half cup)
Vegetables (serving size: half cup)
Skim or Reduced Fat Milk or Soy (half cup)
Sweet or salty snacks (cookies, chips, candy)
Water
100% Juice (half cup)
Soda, sport drink, not 100% juice, tea (half cup)

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* 13. Do you ever shop at a Farmer's Market?

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* 14. Did you know that the Farmer's Market accepts SNAP / EBT / food stamps?

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* 15. Since this time last year, in which of the following Down East Partnership for Children programs have you or your children participated? Check all that apply.

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* 16. Which of the following programs do you think would help promote nutritious eating and physical activity for your child(ren)? Check all that apply.

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* 17. Does your child attend a childcare center?

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* 18. Which best describes your racial/ethnic background?

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* 19. Please check the "Online" option. (This is for our data management purposes.) Thank you!

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