Take a Step Follow-Up Survey

Please fill out this brief survey so we may continue to move towards a healthier community.

Re-Edit Survey
If you want to re-edit this survey later, provide a password:

Or, if you previously entered a password, and want to access your information:
Enter password to re-edit a survey

Question

Response

Which kit did you receive?

Physical Activity
Walking
Running
Healthy Breakfast
Fruits, Vegetables & Whole Grains
Sugar and Fats
Second-Hand Smoke
Personal Tobacco Use

Where did you receive your toolkit?

County Fair
Health Fair
Community Event
Workplace
Workshop/Conference

Was the information in the kit helpful?

Yes No

Please rate the material in the kit:

Too basic
About right
Too advanced
Not applicable

Did you "Take a Step to Health" and make a change?

Yes No

Do you feel an increase in your overall well-being?

Yes No

Would you have made this change if you had not received this toolkit?

Yes

Unsure

Did you recommend this project to others?

Yes

Planning to

What is your county of residence?

Amador
Calaveras
Other

What is your gender?

Male

Female

What is your age group?

Under 18
18-25
26-40
41-55
Over 55

Number of children living in your household Ages 0-5:

0
1
2
3
4 or more

Number of children living in your household Ages 6-18:

0
1
2
3
4 or more