HUB2 Program Evaluation Question Title Please enter your contact information First Name: Last Name: Email address: Confirm email address: Personal Phone Number (Use this format: 000-000-0000): Question Title Employment I am a St. Luke's employee My spouse is a St. Luke's employee Question Title What is your (or your spouse's) St. Luke's employee ID number? St. Luke's employee ID must be a six digit number. If it's less than six digits, add a zero in front. (Examples: 123456, 012345, 001234) Question Title Work Location: East region (Jerome, Magic Valley, Wood River) West region (Elmore, McCall, Treasure Valley - Boise, Eagle, Meridian, Nampa, Fruitland, Baker City) Question Title Baby's Due Date Date Date Question Title Actual Delivery Date Date Date Question Title Baby's Gender Female Male Question Title Did you begin prenatal care prior to 12 weeks gestation? Yes No Question Title At entry into the HUB2 program, how much were you working? Part-time Full-time Other (please specify) Question Title Up to the time of your delivery, how much were you working? Part-time Full-time Other (please specify) Question Title What type of work do you do? Nursing Staff Other clinical staff Administrative/Clerical Non-clinical support Other (please specify) Question Title Did your work require you to lift anything greater than 45 pounds as part of your daily work? Yes No Question Title Did your work require you to stand or walk longer than 4 hours per shift? Yes No Question Title Did your healthcare provider prescribe/recommend any restrictions on your work or activities? Yes No If yes, what were they? Question Title Did you smoke or use tobacco during your pregnancy? Yes No Quit during pregnancy, please list date: Question Title Did you drink any alcohol during your pregnancy? Yes No Question Title How much weight did you gain during your pregnancy? Question Title How well do you feel you are coping with stress since giving birth? Question Title Do you feel you have had healthy eating habits since giving birth to your baby? ("Healthy eating" can be defined as 5 or more servings of fruits or veggies per day, 0-2 servings of fast food or processed snacks per week, and less than one sugar-sweetened beverage per week.) All of the time Some of the time Rarely Not at all Question Title On average, how many days per week do you engage in moderate physical activities for 30 minutes or more? Moderate = physical effort enough to break a light sweat, cause you to breathe harder and your heart to beat faster than normal. 0 - 1 day 2 - 3 days 4 days 5 or more days Question Title On average, how many TOTAL minutes per week are you physically active or exercising at a moderate level (it does not have to be all at one time)? Less than 60 minutes 61 - 120 minutes 120 - 150 minutes 150 or more minutes Question Title How confident are you that you can maintain a regular exercise routine since giving birth to your baby? Very confident Somewhat confident A little confident Not at all confident Question Title Are you still breastfeeding? Yes No Next
