New Jersey Department of Health

Office of Minority and Multicultural Health

FaithFul families participant eXIT SURVEY

ID Number:
Faith Community Name:
Today’s Date:
City:
Zip:
Email:
Sex:	Female Male
TELL ME ABOUT YOU!
1.	What is your age group?

Under 25

25 - 34

35 - 44

45 - 54

55 - 64

65+	2.	Programs in which you and your family participate:

Child Nutrition (Free/Reduced Lunch)

HeadStart

SNAP (EBT Card)

Food Pantry

WIC

New Jersey Family Care

3.	Which of the following social media websites did you use while in the Faithful Families program?

Facebook	Twitter	I did not connect with social media

4.	How often did you connect with Faithful Families social media over the course of our classes?

More than once a day	Once a week

Once a day	I did not connect

Less than three times a week

5.	In what ways did you use Faithful Families social media?

Read tips and recipes	Watched videos about healthy eating of physical activity

Received reminders for upcoming classes	Other, list: _______________________________

Talked with other class participants

5.	If you connected with Faithful Families using social media, please rank how helpful the information was:

Very	Slightly	No help

Reminders of classes	Helpful	Helpful	Helpful	at all	I did not use

Nutrition and physical	Very	Slightly	No help

activity information	Helpful	Helpful	Helpful	at all	I did not use

Very	Slightly	No help

Recipes	Helpful	Helpful	Helpful	at all	I did not use

Connecting with others	Very	Slightly	No help

in the class	Helpful	Helpful	Helpful	at all	I did not use

Very	Slightly	No help

Other, list: ________________	Helpful	Helpful	Helpful	at all	I did not use

TELL ME ABOUT WHAT YOU USUALLY DO!
This is a survey about ways you plan and fix foods for your family. As you read each question, think about the recent past. This is not a test. There are not any wrong answers. If you do not have children, just answer the questions for yourself.
(Circle one)
1	How often do you plan meals ahead of time?	Never	Seldom	Sometimes	Most of the time	Always
2	How often do you compare prices before you buy food?	Never	Seldom	Sometimes	Most of the time	Always
3	How often do you run out of food before the end of month?	Never	Seldom	Sometimes	Most of the time	Always
4	How often do you shop with a grocery list?	Never	Seldom	Sometimes	Most of the time	Always
5	This question is about meat and dairy foods. How often do you let these foods sit out for more than two hours?	Never	Seldom	Sometimes	Most of the time	Always
6	How often do you thaw frozen foods at room temperature?	Never	Seldom	Sometimes	Most of the time	Always
7	When deciding what to feed your family, how often do you think about healthy food choices?	Never	Seldom	Sometimes	Most of the time	Always
8	How often have you prepared foods without adding salt?	Never	Seldom	Sometimes	Most of the time	Always
9	How often do you use the “Nutrition Facts” on the food label to make food choices?	Never	Seldom	Sometimes	Most of the time	Always
10	How often do your children eat something in the morning within 2 hours of waking up?	Never	Seldom	Sometimes	Most of the time	Always
11	How often do you eat meals or snacks with one or more family members?	Never	Seldom	Sometimes	Most of the time	Always
12	On average how many servings of vegetables do you eat per day? Some examples of one serving of vegetables are 1 cup of raw, leafy vegetables like lettuce or greens (about the size of a baseball), ½ cup of chopped vegetables such as carrots (about the size of a computer mouse) or 10 French fries (about the size of a deck of cards.)	None	1	2	3	4+
13	On average, how many servings of fruit do you eat per day? Some examples of one serving of fruit would be one medium apple, orange, pear, or banana, or ½ cup of chopped or canned fruit (about the size of a computer mouse.)	None	1	2	3	4+
14	On a typical day, how many times do you drink sugar-sweetened beverages? (Sugar-sweetened beverages are soft drinks (soda or pop), fruit drinks, sports drink, tea and coffee drinks, energy drinks, sweetened milk or milk alternatives, and any other beverages to which sugar, typically high fructose corn syrup or sucrose (table sugar), has been added.)	None	1 times/ day	2 times/ day	3 times/ day	4+ times/ day
15	How often do you use MyPlate to make food choices?	Never	Seldom	Sometimes	Most of the time	Always
16	How many days per week do you get at least 30 minutes of moderate exercise? Moderate exercise is where your heart beats faster than normal and you can talk, but you can’t sing. Examples include fast walking, aerobic class, strength training, and swimming gently.	0	1	2-3	4-5	6-7
Thank you for completing the survey!

FaithFul families participant eXIT SURVEY

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New Jersey Department of Health

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2016-01-11

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