To be completed by ISU:                                    Participant ID ________________________________

**Innovations in Nutrition Program Evaluation Instructions**

**PURPOSE**

The goal of the Innovations in Nutrition Program**Evaluation Project is to monitor the impact of the congregate meal program on the following behaviors: Confidence in making preventive nutrition choices; nutritional risk; dietary intake frequency; and loneliness.  Other measures that will be assessed for sociodemographic and qualitative purposes include food security classification, and hospitalizations.

**DESIGN**

This study uses a control group design. Tim Getty will oversee the distribution of questionnaires in Linn and Jones Counties. ISU will oversee the distribution of questionnaires in Story and Polk Counties. 

· Control Sites: Senior apartments in Story and Polk Counties 

· Semi Control Site: Jones County Senior Center (receiving traditional meal program)

· Treatment Sites: Marion Public Library, Marion Lowe Park, Central City Senior Center

Evaluation Forms:

Sarah will email the three questionnaires (Pre, Mid, Post) files to Tim Getty (copying Alexandra Curtis). Tim will print the questionnaires on different color paper will be used to easily identify groups. 

· TREATMENT = White paper

· SEMI CONTROL = Pink paper

Sarah will print the control group questionnaires on light blue paper. ISU will oversee all coding of the questionnaires.

Evaluation Dates:

The questionnaires will be distributed at three time points in 2019:  

· February

· July

· October

For the treatment and semi-control sites, distribute the questionnaires on a busy meal day. Doing so will increase the number of respondents. The questionnaires should be distributed by Tim Getty or a member of his team. 

Evaluation Distribution:

The evaluations take on average 15 minutes to complete.  Please take pens for participants to use.  Do not use pencils as the answers can “smudge.” These evaluations are to be distributed to participants when participants arrive at the meal site or senior apartment complex.  

Each participant who returns a questionnaire is to receive a small gift. Due to costs and limited numbers, no gifts can be distributed to those who did not complete a questionnaire.

The questionnaires are to be completed individually.  If the questionnaire distributor wishes to read the questions out loud to participants it will be important to allow for additional time (~15 additional minutes).  Before collecting the questionnaires, please review to ensure all questions are completed. If a participant has left a question blank, please ask if it was intentional. If it was, that is fine. If not, please ask them to complete it. 

The evaluation forms should be mailed or returned to Iowa State University within 2 weeks of completion.  Prior to mailing these, email Dr. Sarah L. Francis (slfranci@iastate.edu) to let her know how many surveys are being mailed.  **ISU ADDRESS: Sarah L. Francis ISU, Dept. Food Science and Human Nutrition, 220 MacKay, Ames, IA 50011-1123.**

**THIS PAGE WILL BE REMOVED WHEN RETURNED TO CAMPUS AND AN ID NUMBER IS GIVEN.  YOUR NAME WILL NOT APPEAR ANYWHERE ON YOUR QUESTIONNAIRE.**

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**PLEASE PRINT YOUR ANSWER**

FIRST NAME: _________________________________________

LAST NAME: __________________________________________

LOCATION OF SURVEY (Please put an ‘X’ by your response):

**Intentionally Left Blank**

**For each of the following items, mark the number that best describes your current beliefs. How certain are you that you could overcome the following barriers?**

**For each of the following items, please mark your level of agreement with the following questions.**

**The below questions are intended to help us better understand who is completing these questionnaires. The completion of this is voluntary. No names will be associated with these questionnaires.**

1. **During the past 3 months, how frequently have you attended a senior meal program? (e.g., lunch at a senior center, Encore Café)**

· I do not attend lunch at a senior center

· I receive Meals on Wheels

· Every day it’s offered

· 3 or more times weekly, but not daily

· 2 times weekly

· 1 time weekly

· 1 to 2 times monthly

2. **How old are you?**______ (years)

3. **Are you male or female?**

· Female

· Male 

4. **Which one or more of the following would you say is your race?**

· American Indian or Alaska Native 

· Asian

· Black

· Hispanic

· Native Hawaiian or other Pacific islander 

· White 

· Other, please describe:

5. **What is the highest degree of school you completed?**

· Less than High School

· High School/GED

· Some College

· Associates

· Technical School

· Bachelor’s

· Graduate

6. **Are you...?**

· Divorced

· Married

· Separated

· Single, never married

· Widowed

7. **What best describes your current living arrangement?**

· Assisted Living Facility 

· Community-residing (e.g. own home, townhome, or apartment [not specifically for older adults], living with adult child or roommate, not in retirement community, etc.)

· Retirement community

· Senior Apartment Complex

· Other

8. **What is the *primary* source of your monthly income?**

· Full-time work

· Part-time work

· Retirement Funds

· Social Security

· Spouse

· Stock Portfolio

· Other (e.g. Pension)

9. **In general, how would you describe your health?**

· Very poor

· Somewhat poor

· Average

· Somewhat good

· Very good

10. **Mark all the health conditions that you have been told you have.**

· Cardiovascular disease (e.g. heart attack, high blood pressure, high cholesterol, etc) 

· Joint issues (e.g., knees, hips, shoulders, etc)

· Arthritis

· Back Issues

· Diabetes

· Lung disease (e.g. asthma, COPD, chronic bronchitis)

· Cancer (including history of cancer)

· Neurological (e.g., stroke, Parkinson’s)

· Other

11. **Please rate your level of agreement with this statement: *“I feel my city/town is older adult friendly*” (e.g., offers programs for older adults, ready access to services that promote aging in place, etc).**

12. **During the past 3 months, were you a patient in a hospital overnight?***Overnight means that you were admitted on a different day then when you left. It does not include outpatient clinic visits or non-medical stays like staying with a family member.*

· Yes

· No

13. **During the past 3 months, how many different times did you stay in any hospital overnight or longer?***Do not count the total number of nights, just the total number of hospital admissions for stays, which lasted 1 or more nights.*

**For the below statements, please indicate if the statement was often true, sometimes true or never true for you/your household in the last 12 months.**

14. **I/We worried whether my/our food would run out before I/we got money to buy more.**

· Often true

· Sometimes true

· Never true

· Don’t know 

15. **The food that I/we bought just didn’t last and I/we didn’t have money to get more.**

· Often true

· Sometimes true

· Never true

· Don’t know 

**Thank you for completing this questionnaire.**

MID Questionnaire      1