Ulster County Chronic Disease Prevention Council Inventory

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.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Job title (if applicable)

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* 4. Organization or Company (if applicable)

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* 5. Street Address

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* 6. City

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* 7. State

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* 8. Zip

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* 9. Phone

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* 10. Cell Phone

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* 11. Email

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

Private Sector/Business

Trade/Industry Association

Government

Education

Sports/Fitness

Non-Profit

Transportation

Faith-based

Health/Mental Health Care

Non-traditional Healthcare/Wellness

Community Coalition

Individual Community Member

Other: __________________________________

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

Local communities: _________________________

Ulster County

Multi-County: ________________________________

Hudson Valley Region

State

National

Other: ___________________________

If you checked the box for local communities, multi-county, or other please describe here:

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

Age: Infants

Age: Children

Age: Teens

Age: Adults

Age: Elderly

Socioeconomic Status: Low

Socioeconomic Status:Average

Socioeconomic Status:High

Special Needs - describe below

Gender - describe below

Ethnicity - describe below

Other - describe below

If you checked Special Needs, Gender, Ethnicity, or Other please describe here:

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

Education about active living or physical activity

Education about nutrition or healthy eating

Promoting healthier lifestyles (workplace, school, community)

Improving healthy food access

Improving and promoting recreational/physical activity infrastructure and access

Advocating for policy change to promote healthier lifestyles (healthy foods, physical activity, alternative transportation) and/or to reduce risk factors (i.e. tobacco control measures)

Working directly, one-on-one with individuals/families to improve preventative health related behaviors

Other (please describe)

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

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* 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)?

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

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

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* 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?

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* 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?

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* 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?

Yes

Maybe, tell me more.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Job title (if applicable)

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* 4. Organization or Company (if applicable)

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* 5. Street Address

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* 6. City

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* 7. State

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* 8. Zip

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* 9. Phone

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* 10. Cell Phone

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* 11. Email

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

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

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

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

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

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* 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)?

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

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

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* 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?

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* 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?

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* 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?

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* 23. Who referred you to take this survey?