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Toolkit Presentation Survey: October-Mix it Up!
School System: Hart County
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* Indicates required question
Date:
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MM
/
DD
/
YYYY
School:
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North Hart Elementary School
Is this the first HealthMPowers presentation you have attended this school year?
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Yes
No
What is your sex?
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Male
Female
What is your age?
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18-59
60+
Are you Hispanic or Latino?
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Yes
No
What is your race?
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American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Other
Please reply with the letter choice that best describes your intent on eating more fruits.
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A. I am not thinking about eating more fruits.
B. I am thinking about eating more fruits and plan to start within 6 months.
C. I am definitely planning to eat more fruits in the next month.
D. I am trying to eat more fruits now.
E. I am already eating 2 or more servings of fruits per day.
Please reply with the letter choice that best describes your intent on serving more fruits to your child.
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A. I am not thinking about serving my child more fruits.
B. I am thinking about serving my child more fruits and plan to start within 6 months.
C. I am definitely planning to serve my child more fruits in the next month.
D. I am trying to serve my child more fruits now.
E. I am already serving my child 2 or more fruits per day.
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