Screening Survey All of the information provided through this survey is strictly confidential. The information gathered will not be shared with any outside sources nor will it be shared with Human Resources. Your personal information will never be publicly connected to any responses indicated below. Question Title * 1. Do you agree to the terms outlined in the the provided waiver/agreement? Yes No Question Title * 2. Please type your first and last name here along with the date as your Electronic Signature. (Example: Jane Doe 09/01/2020) Question Title * 3. What is your full name? Question Title * 4. Please provide your most used email address. We will NOT bombard your email. It is for your login to Challenge Runner, our platform for Elevate. Question Title * 5. How do you identify? Male Female Question Title * 6. What is your current age? Question Title * 7. How tall are you? Question Title * 8. How much do you currently weigh? Question Title * 9. Where are you currently employed? Question Title * 10. On average, how often do you participate in cardio activity each week? 150 minutes or more per week (2 hours and 30 minutes a week) Between 90 minutes and 150 minutes per week Less than 90 minutes per week Question Title * 11. On average, how often do you participate in strength training per week? At least 30 minutes 2 to 3 times per week Once a week for 30 minutes I do not participate in weight lifting. Does lifting out of the bed count? Question Title * 12. On average, how often do you participate in flexibility and balance training per week? At least 30 minutes 1 to 2 times per week (Yoga) I occasionally stretch but not for 30 minutes and not every week I do not stretch. Stretching, what is stretching? Question Title * 13. On average, how many cups of vegetables do you eat each day? I regularly eat 2 to 3 cups each day I eat 1 to 2 cups each day I rarely eat vegetables. Ew, what are vegetables? Question Title * 14. On average, how many cups of fruit do you eat each day? I regularly eat 2 cups each day I eat 1 cup each day, or two cups occasionally I don't eat fruit. Ew, what is fruit? Question Title * 15. On average, how many ounces of lean protein do you eat each day? I regularly eat 5.5 ounces of lean protein each day (i.e. chicken, fish, tofu, turkey) I eat 5.5 ounces of protein -- half is lean and half is not I eat 5.5 ounces of protein but it is rarely lean (i.e., red meat and pork) Question Title * 16. On average, how many ounces of whole grains do you eat per day? I eat 6 ounces of whole grains (1 oz = 1 slice of whole grain bread, 1/2 cup cooked brown rice, 1 cup of whole grain cereal) 1 eat 6 ounces of grains -- half are whole and half are not; OR I do not eat grains I rarely consume grains that are whole (instead, I eat white rice, white bread, sugar cereal) Question Title * 17. On average, how many cups of vitamin D do you consume each day? 3 cups of dairy (i.e., milk or yogurt) OR 3 cups of non-dairy product (i.e. almond milk, oat milk, or a vitamin D supplement) I consume less than 3 cups of dairy or alternate dairy product I do not consume any dairy or alternate dairy product Question Title * 18. On average, how often do you consume processed sugars? I consume processed sugar less than 4 times per week (i.e., soda, cake, ice cream, candy); most sugar comes from fruits I consume processed sugar occasionally but in moderation I consume processed sugar daily (i.e., soda, sweet tea, candy, etc) Question Title * 19. On average, how often do you add table salt to your food each day? I do not add table salt to my food regularly I add table salt to my food occasionally I love salt. The more salt the better. Question Title * 20. On average, how many ounces of water do you drink each day? I drink half my body weight in ounces of water; OR I drink the "recommended" 8 cups I occasionally drink half my body weight in ounces of water; OR I occasionally drink 8 cups, but not often Water? Who needs water? Question Title * 21. On average, how would you say you handle stress each day? I am generally happy and optimistic most of the time. I have good coping strategies for stress. I currently feel somewhat stressed. I could do better with coping with stress. I feel down and/or stressed more often than not. I cope poorly with stress. Question Title * 22. On average, how much sleep do you get per night? I sleep between 7 to 9 hours each night I sleep between 5 to 7 hours each night I sleep less than 5 hours each night Question Title * 23. On average, how often do you use tobacco each day? I do not use any tobacco products (i.e., cigarettes, vape, e-pen, or chewing tobacco) I use tobacco occasionally in social settings or during stressful times I use tobacco daily I prefer not to answer Question Title * 24. On average, how often do you consume alcohol? I consume less than 2 drinks each day I consume between 2 and 4 drinks each day I consume more than 4 drinks each day I prefer not to answer For the activity portion of Elevate, please sign up for our new challenge Move Around Jackson County! Follow the link and click "sign-up" - Move Around Jackson County By submitting the following survey, you understand and agree that you are not guaranteed to be individually rewarded through incentives or prizes while participating in the Elevate program. Done
