* 1. Select your grade.

* 2. Yesterday, did you eat...

  Yes, I ate this at school
(including after-school program)
Yes, I ate this outside school No
a. French fries or other fried potatoes
b. Green salad
c. Vegetables (Do not include green salad, French fries or other fried potatoes)
d. Fruit (Do not include fruit juice)
e. Hot dogs, corn dogs, or hamburgers
f. Pizza
g. Fried chicken or chicken nuggets (Do not include other types of chicken)
h. Candy of any kind
i. Ice cream or frozen yogurt
j. Other sweets like cake, cookies, donuts, pop‐tarts, brownies, sweet rolls, etc.
k. Chips like tortilla chips, potato chips, corn chips, Cheetos, cheese puffs, pork rinds, etc.

* 3. Yesterday, did you drink…

  Yes, I drank this at school
(including after-school program)
Yes, I drank this outside school No
a. Milk
b. Regular soda or soft drinks (do not include diet drinks)
c. Sports drinks, such as Gatorade and Powerade
e. 100% fruit juice, such as orange juice, apple juice or grape juice (do not include fruit‐flavored drinks, Sunny Delight, aguas frescas, sport drinks, Icees, sweetened coffee or tea, Vitamin Water, Koolaid, etc.)
f. Sweetened juice drinks or other sweetened drinks, such as fruit‐flavored drinks, Sunny Delight, aguas frescas, sport drinks, Icees, sweetened coffee or tea, Vitamin Water, Kool-aid, etc.
g. Water, out of the tap, from a water fountain, dispenser or from a bottle (or any unsweetened water)

* 4. Yesterday, how many servings did you eat or drink of…

  none 1 serving 2 servings 3 servings 4 or more servings
a. French fries or other fried potatoes
b. Green salad
c. Vegetables, any kind (Do not include green salad or fried potatoes)
d. 100% fruit juice
e. Fruit, any kind (Do not include fruit juice)

* 5. In the last 7 days, how many times did you eat or drink anything from a fast food restaurant? (For example, McDonald’s, Pizza Hut, KFC, Taco Bell, etc.)

* 6. During the past 7 days, on how many days did you eat breakfast?

* 7. Where do you usually get your lunch during a school day?

* 8. How important for your health do you think it is to…

  Not at all important Somewhat important Important Very Important I don’t know
a. Eat vegetables
b. Eat fruits
c. Drink low-fat milk
d. Drink water
e. Eat high fiber foods

* 9. Did you eat the school breakfast yesterday?

* 10. Did you eat the school lunch yesterday?

* 11. About how often are you given candy, cookies, cake or that kind of food in class as part of a party or as a reward?

* 12. How often do you think the school meals are healthy?

* 13. How often do you think the school meals taste good?

* 14. How many new fruits and vegetables have you tried (or started eating) this school year?

* 15. How much do you agree with the following sentences?

  I agree a lot I agree a little I disagree a little I disagree a lot
This year I've learned more about what makes up a healthy snack
This year I've learned more about what physical activities make your heart beat fast

* 16. Have you participated in the Backpack Program (which gives you food to eat at home)?

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