Small Group INITIAL and POST Survey Questions

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* 1. Please share your FIRST and LAST name and contact information:

Name:

Address:

City/Town:

ZIP:

Email Address:

Mobile Phone:

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* 2. What is your birthday?

Date

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* 3. Organization Name:

Other (please specify)

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* 4. Which program are you completing this survey for?

Eat Right For Life

Eat Right For Life - Family Plan

A Good Night's Sleep

Financial Wellness @ Work

The Road to Wellness

Stop Stress This Minute

Walking for Wellness

Action for Happiness

ACE Your HRA

Freeze the Gain

Other

Other (please specify)

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* 5. Are you taking this as an INITIAL program survey or POST program survey?

INITIAL Survey

POST Survey

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* 6. Program BEGINNING DATE (for INITIAL survey) or ENDING DATE (for POST survey).

Date

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* 7. What is the FIRST and LAST name of your program facilitator?

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* 8. Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the BEST POSSIBLE LIFE FOR YOU and the bottom of the ladder represents the WORST POSSIBLE LIFE FOR YOU. Indicate where on the ladder you feel you personally stand right now.

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* 9. On which step do you think you will stand about five years from now?

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* 10. DID YOU KNOW? 47% all deaths in the U.S. could have been avoided by simply getting regular physicals, according to the Partnership to Fight Chronic Disease. Please check the health system your primary care provider is associated with:

Prevea Health

Aurora

Door County Medical (Ministry)

Bellin Health

ThedaCare

I need a primary care provider

Other (please specify)

Question Title

* 1. Please share your FIRST and LAST name and contact information:

Question Title

* 2. What is your birthday?

Question Title

* 3. Organization Name:

Question Title

* 4. Which program are you completing this survey for?

Question Title

* 5. Are you taking this as an INITIAL program survey or POST program survey?

Question Title

* 6. Program BEGINNING DATE (for INITIAL survey) or ENDING DATE (for POST survey).

Question Title

* 7. What is the FIRST and LAST name of your program facilitator?

Question Title

* 8. Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the BEST POSSIBLE LIFE FOR YOU and the bottom of the ladder represents the WORST POSSIBLE LIFE FOR YOU. Indicate where on the ladder you feel you personally stand right now.

Question Title

* 9. On which step do you think you will stand about five years from now?

Question Title

* 10. DID YOU KNOW? 47% all deaths in the U.S. could have been avoided by simply getting regular physicals, according to the Partnership to Fight Chronic Disease. Please check the health system your primary care provider is associated with:

Question Title

* 11. What is your primary care providers name?