1. DCCPHC National Night Out Family Challenge Survey

You will be sent this same survey in approximately 4 weeks. If you complete both surveys, your name will be included in the draw for 10 Family Fun Packs.

1. Please provide the following information:

Please provide the following information: Name:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2. How many youth under age 21 live in your household?

How many youth under age 21 live in your household?

3. On average, how many servings of fruits and vegetables do members of your family eat per day?

	0-1	2-3	4-5	5 or more
Adults	On average, how many servings of fruits and vegetables do members of your family eat per day? Adults 0-1	Adults 2-3	Adults 4-5	Adults 5 or more
Children	Children 0-1	Children 2-3	Children 4-5	Children 5 or more

4. In a typical week, how many days do members of your family incorporate physical activity for at least 30 minutes?

	0	1	2	3	4	5	6	7
Adults	In a typical week, how many days do members of your family incorporate physical activity for at least 30 minutes? Adults 0	Adults 1	Adults 2	Adults 3	Adults 4	Adults 5	Adults 6	Adults 7
Children	Children 0	Children 1	Children 2	Children 3	Children 4	Children 5	Children 6	Children 7

5. Please read the five statements below. Circle the statement that best describes your current level of healthy eating.

Please read the five statements below. Circle the statement that best describes your current level of healthy eating. I do not eat five servings of fruits and vegetables a day, but I’ve been thinking about starting.

I am trying to eat five servings of fruits and vegetables a day and occasionally eat five servings a day.

I am eating five servings of fruits and vegetables fewer than seven days a week.

I have been eating five servings of fruits and vegetables seven days a week for the last one to six months.

I have been eating five servings of fruits and vegetables seven days a week for at least six months.