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* 1. First Name

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* 2. Last Name

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* 3. Gender

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* 4. Please indicate faculty or staff.

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* 5. Please enter your 9-digit staff ID # (found on your BruinCard):

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* 6. Department

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* 7. Email

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* 8. Do you pledge to take the stairs more often from 12/3 to 12/14?

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* 9. Do you plan to attend at least one of the designated staircase challenges from 12/3 to 12/14?

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* 10. To be eligible for a 12 Staircase Challenge 2-in-1 neck warmer & hat, you must attend at least 3 of the campus challenge locations and the finale. Please indicate the days you plan to attend:

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* 11. Are you currently a member of UCLA Recreation? If not check out our great packages at www.recreation.ucla.edu/newmembers

The following questions are optional, however these questions are geared toward collecting data that will help to develop and improve FITWELL Programs for Faculty and Staff. Responses are confidential and will not be shared.

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* 12. On average, how would you describe your energy level?

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* 13. On average, how would you rate your ability to cope with daily stress?

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* 14. Over the past week, have many times have you engaged in any type of physical activity for more than 30 minutes? (walking, gardening, cleaning, etc.)

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* 15. In which of the following categories would you place yourself?

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* 16. Which of the following FITWELL programs have you participated in? Check all that apply.

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* 17. is this your first time participating in the 12 Staircases of December? 

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