This survey will help the Ulster County Department of Health and Mental Health understand what organizations, businesses, and individuals in Ulster County are doing to prevent chronic disease. The results will be used by the Ulster County Chronic Disease Prevention Council to identify strategies that we can use to coordinate and amplify efforts across the county. To find out more about this survey or the Chronic Disease Prevention Council, contact Kristen Wilson at 845-340-3990 ext. 347 or kew67@cornell.edu. We appreciate your time to fill out this survey. It should take around 15 minutes.

* 1. What is your first name?

* 2. What is your last name?

* 3. Job title (if applicable)

* 4. Organization or Company (if applicable)

* 5. Street Address

* 6. City

* 7. State

* 8. Zip

* 9. Phone

* 10. Cell Phone

* 11. Email

* 12. What community sector(s) does your organization best represent (check as many as apply)?

* 13. What geographic area does your organization serve (check as many as apply)?

* 14. What populations do you serve with respect to chronic disease prevention services, programs, and initiatives? (Check all that apply.)

* 15. How would you classify your chronic disease prevention efforts (check all that apply)?

* 16. What specific programs or initiatives does your organization implement to help prevent chronic disease in Ulster County?

* 17. Has your organization implemented any prevention based programs, initiatives or practices that you are particularly proud of and that have produced impressive results (please describe briefly)?

* 18. Conversely, are there any that have not worked as well but that you learned from to improve your service offerings (please describe briefly)?

* 19. With what organizations do you partner to implement your efforts?

* 20. Are there any potential partners, in the region, that you are aware of that you would like to collaborate more closely with to achieve your mutual goals and the overall goal of preventing chronic disease in Ulster County?

* 21. If you had to choose 3 things/initiatives that we, as a community, could focus on to significantly improve chronic disease PREVENTION efforts and help push forward the goal of making Ulster the healthiest county in New York State, what would they be?

* 22. Would you be willing to become and active representative on the countywide Chronic Disease Prevention Council, which would meet every two months and with a strong commitment to working with others to achieve measurable results?

* 23. Who referred you to take this survey?  

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