1.Congregational Contact Information:

Congregation Name

Address

Office phone

Office fax

Pastor(s) name

Pastor(s) email

Secretary name

Size: Avg. weekly attendance

2.Does your faith organization have an active health ministry or committee?

Don't Know

No

Yes (Who serves on the committee?)

3.Does your faith organization have a person appointed to be responsible for health related activities?

Don't Know

No

Yes (Who?)

4.Has your faith organization ever established health or wellness goals for the faith community?

Don't Know

No

Yes

5.Does your faith organization have a budget for health promotion or health related activities?

Don't Know

No

Yes

6.Does your faith organization wish to start a health ministry or committee for your congregation?

Don't Know

No

Yes (Who should we contact about it)