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

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

Where do you work?

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* 2. Where do you work?

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

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

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

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

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

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

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

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

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

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

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

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

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