Central Illinois Food Bank and Harvard Park Partnership

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Harvard Park Elementary ( Food Bank) Joint Parent/ Guardian & Child Survey

The following questions are about the food situation in your home recently. Please choose the answer that best describes your household. Informed Consent: Participation in this study is completely voluntary. If you decide not to participate there will not be any negative consequences. You will still be able to receive food if you do not complete this survey. These answers will be kept anonymous. The purpose of the survey is to measure changes in Harvard Park Elementary’ s students’ perception of their access to healthy foods, as well as their knowledge regarding making healthy food choices.

For a parent/guardian to complete:

Below are two statements that people have made about their food situation. For each statement, please circle whether the statement was often true, sometimes true, or never true for your household in the last 12 months.

1. “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 12 months?

Often True

Sometimes True

Never True

Clear selection

2. “The food that we bought just didn’t last and we didn’t have money to get more.” Was that often true, sometimes true, or never true for your household in the last 12 months?

Often True

Sometimes True

Never True

Clear selection

3. Did your meals in the last month include fresh fruits and vegetables, such as apples, carrots, or onions?

A Lot

Sometimes

Never

Clear selection

4. Did your meals in the last month include low-fat dairy, such as milk, cottage cheese, or yogurt?

A Lot

Sometimes

Never

Clear selection

5. Did your meals in the last month include lean protein, such as chicken breast, turkey, or fish?

A Lot

Sometimes

Never

Clear selection

Clear form

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