THRIVE! Southern Lorain County Outcomes Survey

THRIVE! Southern Lorain County Outcomes Survey

In an effort to ensure our partners have access to the most current information to make the best decisions about activities in the community, your answers to the following questions would be greatly appreciated.

PLEASE EMAIL THE COMPLETED FORM TO:

Please circle ONE answer each.

Where are you completing this survey?

Inner CircleCommunity EventMetroparks

Farmers MarketOther:______

What is your zip code?

44090 / 44253 / 44275 / 44851 / 44880 / 44859
Other: ______

Community Outcomes

The next 3 questions are required to help track the outcomes of the THRIVE!

Southern Lorain County Collaborative.

On average, how many servings of fruits and vegetables do you consume each day? (A serving can include 1 cup of fruit or vegetables, 2 cups of leafy greens or 8oz. of 100% fruit juice)

1 - 2 Servings per day / 0 - Do not like Fruits and Vegetables
3 - 4 Servings per day / 0 - Can not afford Fruits and Vegetables
5 or more Servings per day / 0 - Do not have access to Fruits and Vegetables

During the last 7 days, how many times did you drink beverages containing sugar? (Include sodas, sweetened fruit drinks, sweetened fruit drinks mixed with alcohol, and energy drinks. Do NOT include 100% fruit juice, black coffee, unsweetened tea, or artificially sweetened beverages.)

Not at all / 1 per day
1 - 3 times / 2 per day
4 - 6 times / 3 per day
4 or more per day

During the last 7 days, how many days did you engage in some type of physical activity for at least 30 minutes?

No Activity / 3 Days
1 Day / 4 Days
2 Days / 5 or more Days
Not Able To Exercise

Demographics

The questions below are not required. However; by providing this information, our partners are better able to analyze all reporting from across the city to ensure we are tailoring our activities correctly and reaching the population we intend to reach.

Your Gender
Male / Female
Other:______
Your Age Range
Under 18 / 18 - 24 / 25 - 34
35 - 44 / 45- 54 / 55- 59
60 - 64 / 65 - 74 / 75 +
Number of individuals in your household / Household Income Range
1 / 2 / Less than $25,000 / $25,000 - $49,999
3 / 4 / $50,000 - $74,999 / $75,000 - $99,999
5 / 6 / $100,000 - $149,999 / $150,000 - $199,999
7 / 8+ / $200,000 +

If you would like to be added to the THRIVE! Email list, please provide your email address. Your contact information will not be shared or sold outside of the collaborative partners.