Survey 1: 3rd to 5th graders POMAIKAI EL

Hawaii 5210 Be Well at School Project

The University of Hawaii School of Medicine, in partnership with your school, is conducting this project. The goal of this project is to improve the health of kids in Hawaii by understanding what kids drink throughout the day. We would like to ask you to please answer the questions below. We expect that the students in Grades 3 through 5 from your school, and about 15 other schools, will participate in the survey. Your honest answers are important and will help us understand what kids choose to drink.
It’s your choice: It should take about 10 minutes to complete this survey. However, if for any reason, you do not want to answer some, or all of these questions, you don’t have to. Your decision will not affect your school grades at all.
Please do not put your name on the answer sheet. We don’t want anyone to know how you answered the questions. We will collect the answers from all the students from your school and let you know the results.

Question Title

* 1. How old are you?

Question Title

* 2. What grade are you in?

3rd

4th

5th

Question Title

* 3. Are you a boy or girl?

Boy

Girl

Question Title

* 4. What have you had to drink today? You may check more than one answer.

Milk

100% Juice (For example: orange or apple juice, coconut water)

Juice drink (For example: Capri sun, fruit punch, Sunny Delight, Kool-Aid, Vitamin Water)

Soda (For example: Coke, Sprite, Pepsi, Mountain Dew)

Sports drinks (For example: Gatorade, PowerAde)

Sweet iced tea (For example: Arizona Tea, Lipton Tea, Frappuccino)

Water

Some other drink:

Question Title

* 5. What did you drink after school yesterday? Include everything you drank until you went to sleep last night. You may check more than one answer.

Milk

100% Juice (For example: orange or apple juice, coconut water)

Juice drink (For example: Capri sun, fruit punch, Sunny Delight, Kool-Aid, Vitamin Water)

Soda (For example: Coke, Sprite, Pepsi, Mountain Dew)

Sports drinks (For example: Gatorade, PowerAde)

Sweet iced tea (For example: Arizone Tea, Lipton Tea, Farppuchino)

Water

Some other drink:

Question Title

* 6. How many cups of water have you had to drink today?

None, I did not drink water today.

About 1 cup

About 2 cups

3 cups or more

Question Title

* 7. Do you like to drink water?

No - I do NOT like to drink water.

Sort of - I like to drink water sometimes.

Yes, I like to drink water every day.

Question Title

* 8. Did you bring a water bottle to school today?

Yes

Question Title

* 9. If you did bring a water bottle, what's in the water bottle?

Water

Juice or juice drink

Sports drink such as Gatorade

Iced tea or coffee with sugar

I did not bring a water bottle to school today

Some other drink:

Thank you for answering this survey! We appreciate your time.