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White Shield Physical Activity Access Survey
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1.
Are you a current resident of White Shield Segment?
(Required.)
Yes
No
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2.
Age:
(Required.)
18-24 years
25-44 years
45-60 years
61 years and older
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3.
Gender:
(Required.)
Male
Female
Other
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4.
Did you use the old walking path in the community? (Check one)
(Required.)
Multiple times per day
Daily
Weekly
Monthly
Never
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5.
Which of these facilities have you used? (Check All that Apply)
(Required.)
Outdoor Walking Path
Outdoor Track
Community Center Fitness Area
Community Center Indoor Track
Community Center Gym
Community Center Pool
Community Center Therapy Pool
Community Center Golf Simulator
Rodeo Ground
None
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6.
How often do you use the facilities listed above? (Check One)
(Required.)
Multiple times per day
Daily
Weekly
Monthly
Never
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7.
What are the main uses of the facilities for you? (Check All that Apply)
(Required.)
Access within the community: store, school, community building, etc.
Exercise
Recreation
Healthy Lifestyle changes
Social Interaction
Other (please specify)
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8.
Are you satisfied with the facilities in your community? (Check One)
(Required.)
Yes
No
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9.
How often do you participate in physical activities (walking, running, biking, gym, sports, etc.)?
(Required.)
Once a week
2-3 times a week
4-5 times a week
6+ times a week
Never
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10.
What suggestions do you have to improve access to physical activity in the White Shield Community?
(Required.)
