Rethink Your Drink -- Online Reporting Survey
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Activity Information
Please complete the survey below to help track local efforts and identify areas for future activities.
1
. Your Name
Your Name
First and Last Name
2
. Name of organization facilitating the activity
Name of organization facilitating the activity
3
. Which sector best describes your organization?
Which sector best describes your organization?
Child Care
Community Organizations
All Employers
Entertainment and Professional Sports
Families
Food and Beverage Industry
Local Government
Health Care Insurers and Providers
Schools
Other (please specify)
4
. Contact Information (phone and/or email)
Contact Information (phone and/or email)
Phone
Email
5
. Date of activity (MM/DD/YY)
Date of activity (MM/DD/YY)
6
. Type of activity
Type of activity
Class
Staff Training
Individual Education
Display
Event
Electronic Media (Website, Facebook, Twitter, etc.)
Outdoor Media (billboards, bus wraps, etc.)
Print Media
Other (please specify)
7
. "Rethink Your Drink" information presented by (select all that apply)
"Rethink Your Drink" information presented by (select all that apply)
Staff/Professional
Youth Volunteer
Adult Volunteer
Other (please specify)
8
. Number of individuals reached by this "Rethink Your Drink" activity
Number of individuals reached by this "Rethink Your Drink" activity
Unknown
Enter exact number (or estimate, if necessary)
9
. Target audience reached (select all that apply)
Target audience reached (select all that apply)
All ages
Perinatal
Birth-5 yrs (Pre-K)
5-12 yrs (Elementary)
13-18 yrs (Junior/High School)
19-35 yrs
36-65 yrs
66+ yrs
10
. Income level of target audience
Income level of target audience
All incomes
Low income (<185% FPL)
Unknown
11
. City where activity was completed
Aliso Viejo
Anaheim
Brea
Buena Park
Costa Mesa
Cypress
Dana Point
Fountain Valley
Fullerton
Garden Grove
Huntington Beach
Irvine
La Habra
La Palma
Laguna Beach
Laguna Hills
Laguna Niguel
Laguna Woods
Lake Forest
Los Alamitos
Mission Viejo
Newport Beach
Orange
Placentia
Rancho Santa Margarita
San Clemente
San Juan Capistrano
Santa Ana
Seal Beach
Stanton
Tustin
Villa Park
Westminster
Yorba Linda
City where activity was completed
Other (please specify)
12
. Which sector best describes the audience reached by this "Rethink Your Drink" activity? (select one)
Which sector best describes the audience reached by this "Rethink Your Drink" activity? (select one)
Families
All Employers
Community Organizations
Child Care
Local Government
Health Care Insurers and Providers
Schools
Food and Beverage Industry
Entertainment and Professional Sports
Other (please specify)
13
. "Rethink Your Drink" materials used (select all that apply)
"Rethink Your Drink" materials used (select all that apply)
Ads
Articles/Fact Sheets
Food Demo/Taste Test
Handouts
Lesson Plan
Pledge Cards
Posters
Teaching Tools (bottles, labels, other)
Other (please specify)
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