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New Town/Four Bears Food Access Survey
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1.
Are you a current resident of New Town/North Segment or Four Bears Segment?
(Required.)
Yes
No
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2.
Age:
(Required.)
18-24 years
25-44 years
45-60 years
61 years and older
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3.
Gender:
(Required.)
Male
Female
Other
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4.
Where do you shop for groceries? (Check all that apply)
(Required.)
New Town
Parshall
Minot
Stanley
Bismarck
Watford City
Williston
Other (please specify)
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5.
How much of your groceries do you buy in New Town? (Check One)
(Required.)
None
Less than one-half
More than one-half
All
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6.
Do you shop for the groceries used in your house? (Check One)
(Required.)
Yes
No
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7.
Are you the primary cook in your household? (Check One)
(Required.)
Yes
No
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8.
How many people are usually at your house for meals? (Check One)
(Required.)
1-5
6-10
11-15
More than 15
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9.
On average, how many meals per week do you or your family prepare/eat home cooked meal?
(Required.)
None
1-4
5-9
10 or more
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10.
On average, how many meals per week do you or your family purchase prepared/takeout/restaurant food?
(Required.)
None
1-4
5-9
10 or more
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11.
Which of the following foods do you/would you buy if they were available in New Town? (Check all that apply & list)
(Required.)
Fresh Fruits (please list)
Frozen Fruits (please list)
Fresh Vegetables (please list)
Frozen Vegetables (please list)
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12.
What type of beverages do you usually buy in New Town? (Check all that apply)
(Required.)
Regular pop
Diet/Sugar-Free Pop
Water
Energy Drink (Red Bull, Monster, 5-Hour Energy, etc.)
Sports Drink (Gatorade, Powerade, etc.)
Juice
Sweetened Tea
Hot Tea
Milkshake
Milk
Coffee
Smoothies
Sparkling or Flavored Water
Other (please specify)
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13.
Do you utilize any food assistance? (Check all that apply)
(Required.)
SNAP
WIC
Commodities
Food Bank/Pantry
None
Other (please specify)
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14.
Do you receive food from any of the following New Town community resources? (Check all that apply)
(Required.)
Farmers Market
Community Garden
Elder's Meal Site
Commodity Program
None
Other (please specify)
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15.
Do you experience any of the following obstacles or challenges to buying the kind of food that you want? (Check all that apply)
(Required.)
Food is too expensive
I don't know what to buy due to lack of knowledge about nutrition
Finding places that accept SNAP or WIC
Stores close to me only sell processed or packaged food
I don't know what to buy because I don't know how to cook
I don't find what I want to buy in the stores nearest to where I live
I don't experience obstacles or challenges when buying food
Other (please specify)
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16.
What information or resources would help you to provide healthier food for your household more often? (Check all that apply)
(Required.)
A store that carries fresh wholesome food near where I live
More money or less expensive food option
Better knowledge of what foods make a healthy diet
Better cooking facilities where I live
Better food storage where I live
Having a vegetable garden at or near where I live
More time to shop and prepare meals
Information on how to buy healthy food
Other (please specify)
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17.
How would you rate the nutritional quality of your diet? (Check one)
(Required.)
Excellent
Very Good
Good
Fair
Poor
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18.
How would you rate your overall health?
(Required.)
Excellent
Very Good
Good
Fair
Poor
19.
What suggestions do you have to improve healthy food options in New Town?
