ATTCHMNT 2A COOKING MATTERS ENG TOOL.PDF

ATTACHMENT 2A
COOKING MATTERS ENGLISH TOOL
FTF-RC00749-0632-00 Page 59 of 185

SNARE OUR STRENGTWS Cooking Matters at the Store for Adults
COOKING
MATTERS Participant Survey
1. What is your sex? 7. How many people TOTAL counting your-
CI Male self live in your household? (This may include
CI Female non-relatives who live with you.)
2. What is your age? El 1 0 4 0 7 0 10 or more
O under 18 O 40-49 0 2 05 El 8
El 18-29 El 50-59 03 El 6 0 9
CI 30-39 0 60 and over
8. How many children ages 0 -5 live in your
3. What is the highest level of education you household? (This may include non-relatives who
have completed? live with you.)
El Less than a high CI Two-year college 0 0 0 2 0 4
school degree degree
Eli O3 O 5 or more
0 High school degree El Four-year college
or GED degree
9. How many children ages 6 -17 live in your
El Some college, but household? (This may include non-relatives who
have not graduated live with you.)
4. Are you Hispanic or Latino?
0 Yes 0 0 O 2 O 4
El No Eli O 3 O 5 or more
5. What is your race? 10. Have you or other members of your household
(You may mark more than one.) participated in any of the following programs in
0 White the last year? (Mark all that apply)
0 Black or African American El WIC
0 Asian El SNAP (formerly Food Stamps)
0 Native Hawaiian or Pacific Islander El Free or reduced-price school breakfast
0 American Indian or Alaska Native 0 Free or reduced-price school lunch
El Other (please specify) El Free or reduced-price school supper
CI Free summer meals
6. Are you pregnant? El Head Start
CI Food Pantry
CI Yes
CI Medicaid
CI No
El Do not participate in any of these programs.
Last Updated: 7/10/2017

11. Tell us what you think about these ways to shop for food. Mark the choice that best matches
your opinion.
This idea I am thinking I am planning I already
is not for about trying in on trying this did this
me. the next 6 on my next before the
months. shopping trip. tour.
What do you think about comparing unit prices to LI LI LI
find the best deal?
What do you think about reading ingredient lists to LI LI LI LI
find whole grains?
What do you think about comparing food labels to LI D LI LI
make healthy choices?
What do you think about buying fruits and vegeta- LI LI El LI
bles in all its forms (fresh, frozen, or canned)?
12. What new ideas did you learn on this tour for saving money or buying healthier food?
13. Overall, what did you think about this tour?
O I REALLY liked this tour.
O I liked this tour.
O I neither liked nor disliked this tour.
O I did not like this tour.
O I REALLY did not like this tour.
FOR STAFF/TOUR FACILITATOR USE ONLY
Tour Month Partner Code Tour Code
Last Updated: 7/10/2017