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Community Captain participant survey
1.
What is your age?
Under 25
25-39
40-59
60-79
80 or over
Prefer not to say
2.
How did you hear about the program?
Social media
Newspaper
Television
Word of mouth
Email
Other (please specify)
3.
Do you currently engage in regular physical activity? (30 minutes or more per day for 5 days a week)
Yes
No
4.
If you currently engage in regular physical activities, answer the following questions.
How many days per week are you physically active?
Approximately how many minutes are you physically active each time?
How long have you been physically active at this level?
What activities do you do?
5.
If you are not currently physically active, how long has it been since you did regular physical activity? (30 minutes or more per day for 5 days a week)
Less than 6 months
More than 6 months but less than a year
More than one year but less than two years
More than two years but less than five years
More than 5 years but less than 10 years
More than 10 years
I have never been regularly physically active.
Other (please specify)
6.
After attending an Active SWV program I intend to:
Remain inactive and not think about becoming more active.
Will remain inactive but think about becoming more active.
Do some physical activity
Participate in regular physical activity (30 minutes or more a day for 5 days a week).
Make physical activity a habit in my daily life.
7.
Please check all that the reasons that apply that have kept you from being physically active.
Lack of time
Lack of encouragement/support/motivation
Lack of enjoyment
Unsafe environment
Injury/fear of injury
Illness
Other (please specify)
8.
What activity(s) were part of your Active SWV experience?
9.
Before participating in the Active SWV program, had you ever visited the program venue?
Yes
No
Don't know
10.
How do you benefit from Active SWV programs?
Current Progress,
0 of 10 answered
