Instructions: Before entering your pre/post Healthy Living survey data, please match your pre- and post-surveys using the Student ID. Then, enter the matched pre- and post-survey results below.
Site or School Name
PRE-TEST: Please enter pre-test responses in this section.
1. Please indicate how hard it would be to complete the following actions.
Eat fruit for a snack
Eat vegetables for a snack
Choose water instead of soda pop or Kool-Aid when you are thirsty
Drink 1% or skim milk instead of 2% or whole milk
Choose a small instead of a large order of French fries
Eat smaller servings of high-fat foods like French fries, chips, snack cakes, cookies, or ice cream
Eat a low-fat snack like pretzels instead of chips
Drink less soda pop
Drink less of other sugary drinks like fruit punch, sports/energy drinks, sweetened teas/coffees
2. Please indicate how often you do each of the following:
I eat vegetables
I eat fruit
I choose healthy snacks
I eat breakfast
I do physical activities
3. Please tell us how often you complete the following tasks.
I do moderate physical activities like walking, helping around the house, raking leaves, or using the stairs.
I exercise 60 minutes every day
4. Please indicate your agreement with the following statements:
Being active is fun
Being active is good for me
Physical activity will help me stay fit
5. Please rate your responses to the following questions about your family.
I encourage my family to eat meals together
Will you ask your family to buy your favorite fruit or vegetable?
Will you ask your family to buy non-fat or 1% milk instead of regular whole milk?
Will you ask your family to have fruits in a place like a refrigerator or bowl on the table where you can reach them?
Will you ask your family to have cut-up vegetables in the refrigerator where you can reach them?
6. Please indicate how often you do each of the following:
I use information to make decisions
I set goals for myself
I take responsibility for my actions
I listen well to others
I am respectful of others
I have the confidence to speak in front of groups
I can work things out when others don't agree with me
I work well with other youth
7. Please indicate your agreement with the following statements:
I am comfortable making my own decisions
I have a plan for reaching my goals
I can explain my decisions to others
I can work successfully with adults
I am connected to adults who are not my parents
I am someone who wants to help others
I like to work with others to solve problems
I have talents I can offer to others
I learned things that helped me make a difference in my community
I helped with a project that made a difference in my community
Please select the responses that best describes you.
8. What grade are you in?
Other Grade (Please Specify):
9. Which of the following best describes your gender?
10. Which of the following best describes your ethnicity?
11. Which of the following best describe your race?
(Mark each box that applies to you.)
POST-TEST: Please enter post-test responses in this section.
5. Please indicate to what extent you agree or disagree that your experience in this UC CalFresh Program (Program) has resulted in the following outcomes.
I learned the foods that I should eat every day
I learned what makes up a balanced diet
I learned why it is important for me to eat a healthy diet
I learned how to make healthy food choices
6. Please indicate to what extent you agree or disagree that your experience in this Porgram has resulted in the following outcomes.
I eat more fruits and vegetables
I eat more whole grains
I eat less junk foods
I drink more water
7. Because of participating in this Program:
My family has purchased healthier foods
My family has prepared healthier foods
My family has prepared meals together
I learned skills for buying food on a budget
I taught my family skills for shopping on a budget
I learned cooking skills
I used cooking skills to prepare food at home
8. Please indicate how often you do each of the following:
9. Please indicate your agreement with the following statements:
Tell us about your UC CalFresh experience.
14. How many years have you been participating in the UC CalFresh Program?
15. Which one of the following best describes how many hours you typically spend in UC CalFresh Program/projects each week?
1. What did you like most about the UC CalFresh lessons?
2. How have you used in your life what you have learned in the UC CalFresh lessons?
3. What parts of the UC CalFresh Program could be better?