*Fit WIC Program*

WIC Participant Survey

*Dear WIC participant: Thank you for taking the time to fill out this
survey. We are just trying to find out what parents such as yourself
think about some nutrition and physical activity issues. We are asking
for your opinion only. Your name will not be on this survey.*

1.  If a friend asked you for advice about feeding children from birth
    to age 5, what tips or advice would you give him or her?

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  Please say whether the following are true for you ***almost always,
    sometimes, or almost never***.

##  Almost Almost

> **Always Sometimes Never**
>
> a\. My family eats the evening meal together.   
>
> b\. I prepare the food my family eats.   
>
> c\. I watch television for 3 hours or more a day.   

d\. I regularly (at least once per week) do physical

activity (such as exercising, dancing, or sports)?   

If yes to "d": please describe the physical activity and the amount of
time you spend doing it during an average week.

+----------------------+----------------------+-----------------------+
| **Activity**         | **Number of days     | ### Numbe             |
|                      | each week**          | r of minutes each day |
+----------------------+----------------------+-----------------------+
| *Ex: play soccer*    | *1*                  | *30*                  |
+----------------------+----------------------+-----------------------+
|                      |                      |                       |
+----------------------+----------------------+-----------------------+
|                      |                      |                       |
+----------------------+----------------------+-----------------------+
|                      |                      |                       |
+----------------------+----------------------+-----------------------+

3.  Do any of the following make it hard for you to do physical
    activity:

## Almost Almost

> **Always Sometimes Never**

a.  I don't feel safe outdoors in my neighborhood ^1^ ^2^ ^3^

b.  I am too tired ^1^ ^2^ ^3^

c.  I don't have time ^1^ ^2^ ^3^

> d\. I would have to do it alone ^1^ ^2^ ^3^

e.  I don't have a place to do it ^1^ ^2^ ^3^

i\. I have to watch my children ^1^ ^2^ ^3^

4.  Compared to other people your own age and sex, would you describe
    yourself as: ***Check only one.***

> ^1^ More physically fit or "in shape" than others
>
> ^2^ About as physically fit or "in shape" as others

^3^ Less physically fit or "in shape" than others

**The next group of questions is about your oldest child in the WIC
program (must be younger than 5 years old).**

5.  Is this child a: ^1^ Boy ^2^ Girl

6.  What is this child's first name:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  What is his/her date of birth:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8.  How tall is he/she (inches): \_\_\_\_\_\_\_\_\_\_

9.  How much does he/she weigh (pounds): \_\_\_\_\_\_\_\_\_\_\_\_\_

10. What size clothing does he/she wear:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11. Please tell me how often the following statements are true for
    \_\_\_\_\_\_\_\_\_\_ (child listed above): almost always, sometimes,
    or almost never:

> **Almost Almost**
>
> **always Sometimes never**
>
> She/he doesn't eat enough ^1^ ^2^ ^3^
>
> She/he eats too much ^1^ ^2^ ^3^
>
> She/he eats too many sweets ^1^ ^2^ ^3^

She/he likes to eat vegetables ^1^ ^2^ ^3^

> She/he is a picky eater ^1^ ^2^ ^3^

I make sure she/he eats all of the

> food on his/her plate ^1^ ^2^ ^3^
>
> I let him/her decide how much he/she eats ^1^ ^2^ ^3^

She/he refuses to eat the meals I make for the family ^1^ ^2^ ^3^

> She/he wants to eat all the time ^1^ ^2^ ^3^

I worry about running out of food during the month ^1^ ^2^ ^3^

If she/he won't eat the family meal,

I prepare something else for him/her. ^1^ ^2^ ^3^

I worry about her/him being too thin. ^1^ ^2^ ^3^

I worry about her/him being too fat. ^1^ ^2^ ^3^

12. In the past seven days, about how many times has your child eaten
    food from a fast food restaurant (like McDonald's, Taco Bell, Burger
    King)? ***Check only one.***

> ^1^ None ^4^ 5-8 times
>
> ^2^ 1 time ^5^ 9 or more times
>
> ^3^ 2-4 times

13. At what age did your child start eating food from fast food
    restaurants?

> ^1^ Before age 1 ^4^ Between 3 and 4 years old
>
> ^2^ Between 1 and 2 years old ^5^ My child does not eat food from
> fast food restaurants.
>
> ^3^ Between 2 and 3 years old

**Now I will read some questions about
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_'s (child mentioned above) activity.**

14. Are there any physical activities (like playing catch, bicycling,
    dancing, etc.) that **you and your child do together**?

^1^ yes

^2^ no

If yes, please list the kinds of activities you do and about how often
you do them:

  ----------------------- ----------------------- ------------------------
  **Activity**            **Number of days per    **Number of minutes per
                          week**                  day**

                                                  

                                                  

                                                  

                                                  
  ----------------------- ----------------------- ------------------------

15. In general, do you think \_\_\_\_\_\_\_\_\_\_\_\_\_ should: ***Check
    only one.***

^1^ Be less physically active than she (or he) is now

^2^ Be about as physically active as she (or he) is now

^3^ Be more physically active than she (or he) is now

^4^ Don't know

16. Do you do as many physical activities **with your child** as you
    would like to?

^1^ Almost always ^2^ Sometimes ^3^ Almost never

If no, why not? **Almost Almost**

**always Sometimes never**

a.  I don't have enough time ^1^ ^2^ ^3^

b.  There aren't safe areas to play ^1^ ^2^ ^3^

c.  There aren't enough activity programs for parents

> and young children ^1^ ^2^ ^3^

d.  I have to watch my other children ^1^ ^2^ ^3^

e.  Other (describe):
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
17. How many hours each day does your child spend sitting and doing
    things like watching TV or videos, playing video games or using a
    computer? ***Check only one.***

> ^1^ Less than one hour per day ^4^ 6 to 8 hours a day
>
> ^2^ 1 to 3 hours a day ^5^ more than 8 hours a day
>
> ^3^ 4 to 6 hours a day

18. What type of childcare do you use:

^1^ A friend or relative takes care of my child

^2^ A family childcare home

^3^ A childcare center (Head Start? ^1^ Yes ^2^ No)

^4^ Other (describe):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^5^ I don't use childcare **(Skip to question 24)**

19. Are you having trouble with any of the following? **Yes No**

```{=html}
<!-- -->
```
a)  Not having enough money for healthy foods ^1^ ^2^

b)  Not having enough safe places for young children to play outside
    ^1^ ^2^

c)  Not having a place to buy fresh foods in your neighborhood ^1^ ^2^

d)  Not having transportation to get places ^1^ ^2^

e)  Not having enough support from family and/or friends ^1^ ^2^

f)  Feeling out of control of what your child eats. ^1^ ^2^

g)  Other (please describe)
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
20. Which of the following do you think are the most common reasons that
    a child under five is overweight?

#### Yes No

a.  Not enough exercise ^1^ ^2^

b.  It is their natural body shape ^1^ ^2^

c.  Not enough self-control ^1^ ^2^

d.  Poor parenting ^1^ ^2^

e.  Eat the wrong foods ^1^ ^2^

f.  Eat a lot ^1^ ^2^

```{=html}
<!-- -->
```
21. Would you participate in the following activities?

> **Yes No**

a.  a\. WIC exercise classes for parents and children together ^1^ ^2^

    b\. Meetings to plan ways WIC can help parents and children be
    healthy ^1^ ^2^

> c\. Cooking classes at WIC ^1^ ^2^
>
> d\. Meetings with other WIC parents to hear stories of what has

c.  worked for them ^1^ ^2^

e\. Working with the WIC staff to make more safe play areas for

> children in my community ^1^ ^2^

22. Would you use the following?

> **Yes No**

a\. A pamphlet from WIC about good nutrition for my child ^1^ ^2^

> b\. A pamphlet from WIC about physical activities to do with my child
> ^1^ ^2^
>
> c\. Information from WIC about how I can make foods

d.  healthier for my children ^1^ ^2^

d\. Educational materials, like books and videos, that I can borrow ^1^
^2^ from WIC and take home

> e\. Information on resources in my community ^1^ ^2^

**We will end with a few more questions about you:**

23. What is your relationship to the child we've discussed?

 mother  foster mother

 father  foster father

 grandmother  other (describe):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

 grandfather

24. How old are you?

> ^1^ 19 or younger ^4^ 30 to 34 ^7^ 45 to 49
>
> ^2^ 20 to 24 ^5^ 35 to 39 ^8^ 50 to 54
>
> ^3^ 25 to 29 ^6^ 40 to 44 ^8^ 55 or older

25. Where were you born?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> City/State Country

26. What is your race/ethnicity? ***Please check all that apply.***

> ^1^ Hispanic/Latino ^5^African American/Black (not Hispanic)
>
> ^2^ Asian ^6^American Indian or Alaskan Native
>
> ^3^ Pacific Islander ^99^Other
> (describe):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ^4^ White (not Hispanic)

27. What is your level of education? ***Please check only one.***

> ^1^ No formal schooling ^7^ AA (Associate's degree)
>
> ^2^ Elementary school ^8^ BA/BS (Bachelor's degree)
>
> ^3^ Junior high/Intermediate ^9^ Graduate school
>
> ^4^ Some high school ^10^ Certification program (eg LVN, dental
> assistant)
>
> ^5^ High school graduate/GED ^99^ Other
> (describe):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ^6^ Some college

28. How many adults live in your household?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many children live in your household?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

29. Are you currently:

^1^ Working ( \_\_\_\_\_\_\_ hours per week)

^2^ In School or Training ( \_\_\_\_\_\_\_ hours per week)

^3^ At home with your children

^4^ Other (describe)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Continue on next page!!**

30. Please check the box of the picture you think is most like your body
    shape.

Female:

![](media/image1.wmf)

Male:

![](media/image2.wmf)

31. Are you currently trying to change your weight?

^1^ Yes, trying to lose weight ***Go to question 38***

^2^ Yes, trying to gain weight ***End of interview---Thank you!***

^3^ No ***End of interview---Thank you!***

32. If yes, are you doing any of the following?

> **Almost Almost**

**always Sometimes never**

a.  Eating less food ^1^ ^2^ ^3^

b.  Doing regular physical activity ^1^ ^2^ ^3^

c.  Watching less TV ^1^ ^2^ ^3^

d.  Eating low fat foods ^1^ ^2^ ^3^

e.  Eating more fruits and vegetables ^1^ ^2^ ^3^

> f\. Other
> (describe):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ***Thank you very much for filling out this survey!***