SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 41B: NUTRITION QUESTIONNAIRE FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and Staff of the University of Nevada HRSA SPNS Cooperative Agreement Project (1996). Module 41B: Nutrition Questionnaire. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Please note that Module 41B is three pages long. All three pages should be completed.

Specific Parts of the Module 41B: Nutrition Questionnaire Form

Please have site staff fill in the following information on the Module 41B form:

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Service Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Please have the client fill in the following information on the Module 41B form:

My Birthdate. Where the boxes specify, have the client enter the numbers representing his/her birthdate. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the birth year (for example, "70" for 1970). Make sure that if a month or day is less than 10, you place a "0" before the number..

My Gender. Darken the circle next to the response that indicates the person's gender.

My Height. Have the client enter his/her height in feet and inches in the boxes provided.

My Weight. Have the client enter his/her weight in pounds. If the client’s weight is less than 3 digits, place a 0 before the number. For example, if the client weighs 95 pounds, he/she would enter "095".

How often do you eat these foods? Darken the circle corresponding to the frequency of your intake. Please name food if you use an "Other" category. For each item listed, have the client darken the circle next to "Never," if he/she does not eat the food mentioned. Darken the circle next to "Several Times a Year," if the client eats the food mentioned only infrequently (less than monthly). Darken the circle next to "About Monthly," if he/she eats the food item at least once every month. Darken the circle next to "A Few Times a Month or Weekly," if the client eats the food item more than one time per month or every week. Darken the circle next to "Daily or More Often," if he/she eats the food item at least once per day. If the client chooses "Other", please have him/her specify the particular food by printing it in the boxes provided.

Specific Parts of Module 41B (Page 2): Nutrition Questionnaire

Please note that Module 41B is three pages long. Before beginning Page 2 of Module 41B Page 1 should be completed.

Please have site staff fill in the following information on the Module 41B, page 2 form:

ID Letters/ID Numbers, Site, Sub-Provider, Service and Date (see instructions above).

Please have the client fill in the following information on the Module 41B form, page 2:

My Birthdate, My Gender, My Height, My Weight (see instructions above).

How often do you eat these foods? Darken the circle corresponding to the frequency of your intake. Please name food if you use an "Other" category. How often do you eat these foods? For each item listed, have the client darken the circle next to "Never," if he/she does not eat the food mentioned. Darken the circle next to "Several Times a Year," if the client eats the food mentioned only infrequently (less than monthly). Darken the circle next to "About Monthly," if he/she eats the food item at least once every month. Darken the circle next to "A Few Times a Month or Weekly," if the client eats the food item more than one time per month or every week. Darken the circle next to "Daily or More Often," if he/she eats the food item at least once per day. If the client chooses "Other", please have him/her specify the particular food by printing it in the boxes provided.

Specific Parts of Module 41B (Page 3): Nutrition Questionnaire

Please note that Module 41A is three pages long. Before beginning Page 3 of Module 41A, Pages 1 and 2 should be completed.

Please have site staff fill in the following information on the Module 41B, page 3 form:

ID Letters/ID Numbers, Site, Sub-Provider, Service and Date (see instructions above).

Please have the client fill in the following information on the Module 41B, page 3 form:

My Birthdate, My Gender, My Height, My Weight (see instructions above).

How often do you eat these foods? Darken the circle corresponding to the frequency of your intake. Please name food if you use an "Other" category. For each item listed, have the client darken the circle next to "Never," if he/she does not eat the fool mentioned. Darken the circle next to "Several Times a Year," if the client eats the food mentioned only infrequently (less than monthly). Darken the circle next to "About Monthly," if he/she eats the food item at least once every month. Darken the circle next to "A Few Times a Month or Weekly," if the client eats the food item more than one time per month or every week. Darken the circle next to "Daily or More Often," if he/she eats the food item at least once per day. If the client chooses "Other", please have him/her specify the particular food by printing it in the boxes provided.