* 1. Please provide your first and last name (to be entered into prize drawings).

* 2. Where do you work?

* 3. Please provide your phone number (to be contacted for prize drawings).

* 4. Do you eat 5 or more servings of fruits and vegetables daily?

* 5. Outside of work or school, do you spend more than 2 hours per day watching TV or on an electronic device?

* 6. Do you perform 1 hour or more of physical activity per day?

* 7. Do you drink 1 or more sugar sweetened drinks per day?

* 8. Please provide any comments you may have regarding the 5-2-1-0 program: