Spring 2007
NEEDS ASSESSMENT SURVEY – RESIDENT OBESITY AND HEALTH MONITORING
With growing problems in health care based on obesity and
lack of proper information regarding health, exercise and nutrition,
To secure funding for the appropriate programs in our community, we are asking that you complete the Resident Obesity and Health Monitoring questionnaire attached.
Please complete the attached questionnaire and submit to the Brown County Health Department (Mail #999) no later than February 15, 2007.
We believe this is a large step forward in securing and educating our community about proper health practices and appreciate your cooperation and comments. Thank you for your time.
Dr. Health Director
RESIDENT OBESITY AND HEALTH MONITORING
We are gathering background information for our program development and evaluation of resident health education and monitoring. Your cooperation is appreciated and we welcome your suggestions and comments.
Q1: Please indicate the role(s) of your department in community-based health programs. (Mark all that apply)
a. Obesity Assessment, Training or Monitoring
b. Adolescent Health Monitoring
c. Alcohol, Drug or Substance Abuse Monitoring
d. Community Health Education and Outreach
e. Nutritional Education
f. Low-Income Assistance Programs in Health, Nutrition
Q2: For your departments role(s), please indicate the approximate number of individuals serviced during all of 2006 and then for the last quarter of 2006 (Oct – Dec).
|
Department |
Total 2006 |
Total 4QR 2006 |
|
Obesity Assessment, Training or Monitoring |
|
|
|
Adolescent Health Monitoring |
|
|
|
Alcohol, Drug or Substance Abuse Monitoring |
|
|
|
Community Health Education and Outreach |
|
|
|
Nutritional Education |
|
|
|
Low-Income Assistance Programs in Health, Nutrition |
|
|
Q3: Of the total number of participants in 2006, what percentage do you believe would benefit from an advanced obesity or health monitoring program?
_________________________ %
Q4: Of the total number of individuals you believe would benefit, what percent do you feel would actively participate in a free health monitoring and education program if offered?
Answer from Q3: _________________ %
Participation %: _________________ %
RESIDENT OBESITY AND HEALTH MONITORING
Q5: Would you, personally, be willing to assist with program development and monitoring, when funding is secured? YES NO
Q6: Do you believe that a program aimed at health education and obesity awareness is an appropriate program for your department? YES NO
Q7: Would you, personally, be willing to encourage and promote this program when funded? YES NO
Q8: What top three items do you believe should be considered in this program?
ITEM 1: ______________________________________________________
ITEM 2: ______________________________________________________
ITEM 3: ______________________________________________________
Q9: What administrative of management considerations do you believe need to be considered with this program?
a. Management cooperation
b. Time to participate
c. More information on the program
d. Public commitment
e. Outreach/Awareness
f. Multi-lingual adaptation of materials/education/awareness
g. All of the above
General Information (please print):
Name: _____________________ Phone/Ext: ________
Department: _____________________ Email: ______________
Center: _____________________
Thank you for your time and cooperation! We will keep you apprised of our efforts and
welcome additional comments and questions.
Please submit your completed
questionnaire to the Brown County Health Department (Mail #999) no later than
February 15, 2007. THANKS AGAIN!