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GAVA COHORT ADULT SURVEY
The following questions are about your neigborhood and your access to certain types of food and physical activity. We will not share your answers with anyone. This survey is completely anonymous and confidential. Please answer the questions to the best of your ability by checking the one answer that is
best for you. Thank you!
First, a few questions about you and your family…. 1. What is your home zip code? ______________ 2. What is your age? __________ years old 3. What is your gender?
Female Male
4. How many adults (older than 18) including yourself live in your household _________ Adults (18+ years)
5. How many children less than 18 years old live in your household? ____________ Number of children
6. How old are each of your children and what school do they attend? _____ years ______________ School
_____ years ______________ School _____ years ______________ School _____ years ______________ School _____ years ______________ School
7. If you have children who are of preschool age (ages 4 or 5), are they in preschool? No – If no, why not? ___________________________________________________ Yes, in public pre-school Yes, in private pre-school
8. What is your ethnicity? (Check all that apply).
African-American or Black
Hispanic or Latino Caucasian or White Other (write):_________________
9. What language do you normally speak at home? Only or Mostly English (skip the next question) Only or Mostly Spanish Both English and Spanish about the same amount Mostly other language (please specify):_________________
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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10. If not a native English speaker, how comfortable are you speaking English? Very beginner (you can speak a few words) Beginner (you can make a few sentences)
Somewhat proficient (you can discuss but still have trouble in a conversation) Very proficient (you have no problem getting your ideas across)
11. In what country were you born? United States Another country
12. How many years have you lived in the United States? ____________ Years 13. For how long have you lived in the Dove Springs Community? ______________Years/Months
14. Are you currently…?: Married or living with a partner Divorced, separated, or widowed
Never married 15. What was your annual household gross income for 2012? (the responses to these questions are for descriptive
purposes ONLY and are CONFIDENTIAL and will NOT be connected to your name). Under $10,000 $10,001-$15,000 $15,001-20,000
$20,001-$25,000
$25,001-$35,000 $35,001-$50,000 $50,001-or greater
16. What is the highest degree or level of school that the person who earns most of the income in the family
has completed? (Check ONE box.) Never atended school Grades Kinder through 8 (Elementary/primary) Grades 9 through 11 (Some high school/secondary)
Grades 12 or GED (High School Graduate) College 1 year to 3 years (some college or technical school)
College 4 years or more (College graduate) 17. Do you have any type of healthcare coverage, including private health insurance or government plans such
as Medicare or CHIP?
No Yes
18. Has a doctor ever told you that you have any of these medical conditions? (Check all that apply) High blood pressure Obesity/Overweight
High Cholesterol Asthma Depression
Diabetes Arthritis
Other- Please specifiy: ___________________________________
None
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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19. Do you have a medical condition that requires you to be on a special diet or limits your physical activity? No Yes
20. How do you usually get around for your daily activities? (one or more may apply) My own car A friend or relative’s car I walk
I take the bus I ride a bike I ride a motorcycle/scooter
ACCESS TO FOOD
21. Do you use a grocery store in your community? Yes, regularly Rarely or never, because it is too far for me Rarely or never, because it is too expensive for me
Rarely or never, because it does not stock the food I like to buy
Rarely or never, because the food is of poor quality Never, because there is no grocery store in my community I don’t know if there is a grocery store in my community
22. Where do you obtain fruits and vegetables for your family? (Check all that apply) Supermarket (i.e. Target, Walmart, HEB, Randalls, Fiesta)
Smaller grocery store (La Micheaoacan, Wheatsville, El Rancho) Convenience store (7-11, gas station) Farmers’ market, mobile vending, farm stand Own garden or community garden
23. Do you use a farmers’ market or farm stand in your community? Yes, regularly – (where?):______________________ Yes, sometimes – (where?):_______________________ Rarely or never
24. If you answered “rarely or never” to question 23, can you tell us why?
It is too far for me It is too expensive for me The produce for sale is poor quality There is no farmers’ market/farm stand in my community
I don’t know if there is a farmers’ market/ farm stand in my community 25. Do you use a “mobile vegetable market” in your community? Yes, regularly Yes, sometimes Rarely or never, because it is too far for me
Rarely or never, because it is too expensive for me Rarely or never, because the produce for sale is poor quality Never, because there is no mobile vegetable market in my community I don’t know if there is a mobile vegetable market in my community
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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26. Do you use a community garden in your community? Yes, regularly Yes, sometimes
Rarely or never, because it is too far for me Rarely or never, because I don’t have time to do gardening Rarely or never, because it is easier to buy fruits and vegetables from a market Rarely or never, because it is hard to grow vegetables and fruits Never, because there is no community garden in my community
I don’t know if there is a community garden in my community No, but I would like to know how to grow food No, but I garden in my home garden
27. Have you had any of the following issues when you buy fruits and vegetables for your family? The fruits and vegetables are of low quality
Poor selection of fruits and vegetables The fruits and vegetables are expensive Not available in stores where I buy food
Other reason: (Please write here)___________________________________________________ 28. Have you ever attended a class that teaches you how to grow your own fruits and vegetables? No Yes (write which one):__________________________________
29. Have you ever attended a class that teaches you how to cook and prepare fruits and vegetables?
No
Yes (write which one):__________________________________ 30. Which of the following type of assistance does your family receive? (Check all that apply) None Free and Reduced Lunch program at school
Food stamps/SNAP (Supplemental Nutrition Assistance) TANF (Temporary Assistance for Needy Families) WIC (Women, Infants & Children) Veteran Benefits
31. Do you run out of food at the end of the month because you can’t afford to buy more? Almost always or always
Sometimes Almost never or never
ATTITUDES
32. How important is it to you that your family eats healthy? Not at all A little
Somewhat A lot
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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33. In your neighborhood, how many people do you know that think healthy eating is important? None A few (1-2)
Several (3-4)
A lot (5 or more) I don’t know
34. In your neighborhood, how many people do you know that purchase fresh fruits and vegetables at a
farmers market or farm stand? None A few (1-2) Several (3-4)
A lot (5 or more) I don’t know
35. In your neighborhood, how many people do you know that purchase fresh fruits and vegetables through a
CSA (Community Supported Agriculture) program? None
A few (1-2) Several (3-4)
A lot (5 or more)
I don’t know
36. At community events in your neighborhood, such as church events or block parties or school events, what
kind of items are usually available? (Check all that apply) Fresh fruit and vegetables Sodas Fruit juice
Pizza Chips and other fried snacks Baked sweets (brownies, churros, cupcakes, cakes)
Candies Ice creams
Other food/drink (write here): ______________________________________________________ 37. If you wanted to eat healthier foods (i.e. more fruits and vegetables, more whole grains, less fat and sugar,
less packaged foods), which of the factors below would make it easier for you to do so (Check all that apply): If there were more locations where I could buy healthy foods in my neighborhood. If the distance to locations I could buy healthy foods was closer to me.
If there was a greater variety of healthy food options at locations in my neighborhood that sell them. If healthy foods were easier to find at locations that sell them in my neighborhood. If the price of healthy foods was lower in my neighborhood.
If unhealthy foods in my neighborhood were more expensive.
If unhealthy foods in my neighborhood were harder to find. If I had more information about what food is healthy and what food is unhealthy If there were coupons or discounts for healthy foods in my neighborhood. If there were rewards, prizes or incentives for buying healthy foods in my neighborhood.
If I knew more about how to make healthy foods If I knew more about how to store healthy foods If I had more space in my kitchen for healthy foods.
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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FOOD AROUND THE HOUSE
38. How often do you have fresh fruits or vegetables available in your home?
Never
Rarely
Sometimes
Often
Always
39. How often do you have frozen, dried, or canned fruits or vegetables available in your home?
Never
Rarely
Sometimes
Often
Always
40. How often do you have sweets like candy, cookies, cake, ice cream available in your home?
Never
Rarely
Sometimes
Often
Always
41. How often do you have sugary drinks like regular (not diet) sodas, sports drinks (Gatorade, Powerade,
etc.), fruit drinks (Capri Sun, Kool-Aid, etc) available in your home?
Never
Rarely
Sometimes
Often
Always
42. How often do you have regular potato chips, corn chips, and cheese puffs like Lays, Doritos, Cheetos, etc.
available in your home?
Never
Rarely
Sometimes
Often
Always
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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EATING HABITS
43. Do you eat fruits and/or vegetables as snacks?
No Yes, sometimes
Yes, often Yes, everyday
44. Do you eat more than one variety of fruit each day? No Yes, sometimes
Yes, often Yes, everyday
45. What is the total amount of fruit you eat each day? (1/2 cup equals approximately one handful) 0 cups
½ cup 1 cup
1 ½ cups
2 cups or more
46. Do you eat more than one variety of vegetable each day (i.e. spinach and tomatoes)? No
Yes, sometimes Yes, often Yes, everyday
47. What is the total amount of vegetables that you eat each day? (1/2 cup equals approximately one
handful) 0 cups
½ cup
1 cup
1 ½ cups
2 cups or more
48. Do you eat 2 or more vegetables at your main meal each day? No
Yes, sometimes Yes, often Yes, everyday
49. During the past week, how many times did you eat a meal from a sit-down or fast food restaurant? Never
A few times (1-2) Sometimes (3-4)
Many times (5 or more)
50. During the past week, how many times did you eat a homecooked dinner at home. Never
A few times (1-2) Sometimes (3-4) Many times (5 or more)
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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51. How often did YOU eat or drink these foods or drinks in the PAST WEEK? (mark one box in each row) FOOD/DRINK ITEM Less than
once per week
About 1 time a week
2-3 times a week
4-6 times a week
Once a day 2 or more times a
day
Eggs
Whole milk or flavored milk
(not low fat or skimmed)
Flour tortillas (not corn)
Hamburgers or cheeseburgers
Tacos, burritos, or enchiladas
Other mixed dishes with meat
Roast pork or chops, roast beef, or steak
Fried chicken
Cheese or cheese spreads
Pizza
Refried beans
French fries or fried potatoes
Potato chips, corn chips, or peanuts
Cake, sweet rolls, doughnuts, or Mexican sweet bread
How often do you use fat or oil to fry, cook, or season?
Salad dressing
Regular sodas (not diet)
PHYSICAL ACTIVITY
52. During the past 7 days, how many times did you exercise or take part in any VIGOROUS physical activity (any activity that makes you breathe fast such as basketball, soccer, running, swimming, fast bicycling) for AT LEAST 20 MINUTES? Never
1-2 times 3-4 times
5-6 times
7 times More than 7 times
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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53. Please check the box of all activities that you have done during the past 7 days. For each activity that was
checked , write down the total # of minutes that you spent doing the activity per day.
Activity Total # Minutes per Day
SUN
MO
N
TUE
WED
THU
R
FRI
SAT
Aerobic Dance/Step Aerobics/Zumba
Basketball
Bicycling (indoor, outdoor)
Bowling
Calisthenics/Toning Exercises
Canoeing/Rowing/Kayaking
Dancing (square, line, ballroom)
Elliptical Trainer
Fishing
Football/Soccer
Gardening or Yardwork
Golf
Hiking
Hunting
Jogging (outdoor, indoor)
Jumping Rope
Martial Arts (karate, judo)
Pilates
Raquetball/Handball/Squash
Skating (roller, ice, blading)
Softball/Baseball
Stairmaster
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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Activity Total # Minutes per Day
SUN
MO
N
TUE
WED
THU
R
FRI
SAT
Strength/Weight Training
Swimming (laps, snorkeling)
Tai Chi
Tennis
Volleyball
Walking for Exercise (outdoor, indoor, treadmill)
Water Aerobics
Yoga
Other _____________________
I did none of these activities over the past 7 days.
54. Was this week reflective of your usual activity levels? YES NO
55. Excluding time at work, in general how many HOURS per DAY do you usually spend watching television or
working on a computer? __________ hours.
56. Over this past week, have you spent more than one day confined to a bed or chair as a result of an injury, illness,
or surgery? YES NO
If yes, how many days over the past week were you confined to a bed or chair?__________ days.
57. Do you have difficulty doing any of the following activities?
a. Getting in or out of a bed or chair? YES NO
b. Walking across a small room without resting? YES NO
c. Walking for 10 minutes without resting? YES NO
PHYSICAL ACTIVITY OPPORTUNITY
58. In general, how safe is it for teens/adults to bike or walk in the neighborhood? Not safe at all If you checked NOT SAFE AT ALL, can you tell us why?: ____________________________________
Mostly safe Very safe
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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59. In general, how safe is it for children to walk or bike to school from your house? Not safe at all If you checked NOT SAFE AT ALL, can you tell us why?: ____________________________________
Mostly safe
Very safe 60. Is there a place to get drinking water in your neighborhood when you are outside being active? No Yes
I don’t know
61. Does your neighborhood have free or low cost public recreation facilities (such as swimming pools, parks, walking trails, bike paths, etc) FOR ADULTS?
No Yes
I don’t know
62. Does your neighborhood have free or low cost public recreation facilities (such as swimming pools, parks, walking trails, bike paths, etc) open to CHILDREN? No Yes I don’t know
63. In general, how would you rate the condition of your neighborhood public recreational facilities?
Poor Fair Good Excellent
I did not know there were facilities in my neighborhood I am aware of the facilities in my neighborhood, but have never used them (Please tell us why
here):___________________________________________________________________________________________________________________________________________________________________
64. Does your neighborhood have playgrounds that are of good quality and safe, for children to use? No
Yes
I don’t know
65. Does your neighborhood have enough free or low cost programs for physical activity for adults? No
Yes I don’t know
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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66. Does your neighborhood have enough free or low cost programs for physical activity for children? No Yes
I don’t know 67. If you said NO to question 65 or 66, what free or low-cost programs do you wish your neighborhood had:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
68. In general, how would you rate the quality of the free or low cost programs in your neighborhood? Poor
Fair Good
Excellent I did not know there were programs in my neighborhood
I am aware of the programs in my neighborhood, but have never attended them (Please tell us why here):___________________________________________________________________________________________________________________________________________________________________
69. What is the general quality of your neighborhood’s sidewalks, streets, and open spaces? Poor Fair Good
Excellent 70. In the past 6 months, how often have you used the recreation center in your neighborhood for physical
activity? 3 or more times a week 1-2 times a week
1-2 times a month Less than once month
If you did, please indicate which one(s): _________________________________________________________________________________
71. In the past 6 months, how often have you used the neighborhood trails or streets for walking? 3 or more times a week 1-2 times a week
1-2 times a month Less than once month
72. In the past 6 months, how often have you used the parks in your neighborhood for physical activity? 3 or more times a week 1-2 times a week
1-2 times a month Less than once month
If you did, please indicate which one(s): ☐ Franklin park ☐ Dove Springs District Park ☐ Ponciana Park ☐ Others (please specify): _____________________________________________________________
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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73. In the past 6 months, how often have you used the playgrounds in neighborhood? 3 or more times a week 1-2 times a week
1-2 times a month Less than once month
ATTITUDES
74. I get as much physical activity as I would like. (Please answer for yourself) No, I disagree completely I disagree somewhat
I agree somewhat Yes
75. If you disagree somewhat or completely with the question above, why? (Check all that apply)
The physical activity facilities (trails, parks or recreation centers) in my neighborhood are too far There is too much traffic to walk in my neighborhood
There is too much crime to walk in my neighborhood I don’t have enough time to do enough physical activity
The physical activity facilities (trails, parks or recreation centers) are of poor quality
The physical activity facilities (trails, parks or recreation centers) are not safe I prefer doing sedentary activity like watching TV I don’t have anybody who will do physical activity with me
76. I feel it is important for my family to be physically active.
Not at all A little
Somewhat A lot
77. In my neighborhood, a lot of people walk. Strongly disagree Somewhat disagree
Neither agree nor disagree
Somewhat agree Strongly agree
78. In my neighborhood, a lot of people ride their bikes. Strongly disagree Somewhat disagree Neither agree nor disagree
Somewhat agree Strongly agree
79. In general, do you feel like your neighborhood is a safe place for your child to play outside? Strongly disagree
Somewhat disagree Neither agree nor disagree
Somewhat agree
Strongly agree
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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80. Around your child’s school, how much of a problem are the following?
Not a problem Minor problem Moderate problem Serious problem
Theft
Assault
Gangs
Trash and litter
Traffic
Drugs
Other:________________
COMMUNITY PARTICIPATION
81. Please check the appropriate box, to show how strongly you agree with the following statements about
people in your neighborhood:
Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree
People around here are willing to help their neighbors
This is a close-knit neighborhood
People in this neighborhood can be trusted
People in this neighborhood generally don’t get on with each other
People in this neighborhood do not share the same values
82. In the past 12 months have you:
No Yes
Voted in an election (local, state, or national)?
Written or called a local, state, or federal government official about the issue in your community?
Volunteered at your child’s school (e.g. PTA, PTO, SHAC, library, cafetería monitor, classroom assistant)?
Attended a meeting of a school board, city council, or other official government body?
Volunteered for any community organization?
83. Have you heard or seen anything about the Go Austin! Vamos Austin Project before this survey (GAVA)?
(Please check all that apply) No, I haven’t
Yes, from a neighbor Yes, from a flyer Yes, on the radio Yes, at a meeting
Yes, at the recreation center
Yes, at my child’s school Yes, other place (specify):
____________________________
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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QUESTIONS ABOUT YOUR KINDERGARTEN CHILD
Finally, we’d like to ask you some questions about your kindergarden-aged child…
84. How many days per week is your child physically active at least 30 minutes? Less than 1 day per week 2-3 days per week 4-5 days per week
More than 5 days per week 85. Does your child walk or bike to school? No Yes
Why not: ______________________________________________________ 86. How many days per week does your child eat 5 servings of fruits and vegetables (not counting french fries
as a vegetable) Less than 1 day per week 2-3 days per week 4-5 days per week
More than 5 days per week 87. How often do you cook your main meal with at least one vegetable for your child? All of the time Most of the time
Some of the time Never
88. In the last week, how many times did your child eat home-cooked dinner at home with the family? Never 1-2 times
3-4 times 5-7 times
89. In the last week, how many times did your child eat fast food for dinner? Never
1-2 times
3-4 times 5-7 times
90. Do you limit the number of sodas or sugar-sweetened beverages (including flavored milk) that your child
can drink? No, never
Yes, sometimes Yes, most of the time Always
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013
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91. Does your child usually get enough sleep every night? The recommended number of hours of sleep for 4 and 5 year old children is 10-12 hours. No, my child never gets 10-12 hours of sleep
Some nights (1-3 nights per week) my child gets 10-12 hours of sleep
Most nights (4-6 nights per week) my child gets 10-12 hours of sleep My child always gets 10-12 hours of sleep
92. My child’s school has opportunities for:
No Yes
My child to learn about eating healthy.
Me to learn about eating healthy
My child to learn about being active.
Me to learn about being active.
93. Does your child go to an organized after-school program (for example, YMCA)? No Yes
94. How often did YOUR CHILD consume these items YESTERDAY? (mark one box in each row)
FOOD/DRINK ITEM 0 times 1 time 2 times 3 or more
times
Orange vegetables (like carrots, squash, or sweet potatoes)
Salad (made with lettuce or any other Green vegetables like spinach, broccoli, swiss chard)
Beans (like pinto, garbanzo, black or kidney)
Any other vegetables (like tomatoes, asparagus, cucumbers, mushrooms, bell peppers, celery)
Fruit (fresh, frozen, canned or dried)
Punch, Kool-Aid, Sports drinks or any other fruit-flavored drink (DO NOT COUNT 100% Juice)
100% Fruit Juice (like apple, orange, grape)
Regular sodas or soft drinks
A cup or bottle of water
IRB NUMBER: HSC-SPH-13-0108
IRB APPROVAL DATE: 10/08/2013