Survey - screenshots

C2. Screenshots of Survey Questionnaire

Login Screen

Form Approved
OMB No: 0920-xxxx
Expiration Date: xx/xx/xxxx
BURDEN STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance
Officer, 1600 Clifton Road NE, Mailstop D74, Atlanta, GA 30333; ATTN: PRA 0920-xxxx.

Community Confirmation Screen

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Consent Statement

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Questionnaires Menu / Home Page (Respondent has not started any questionnaire sections)

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Contact Us Screen

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Print Blank Paper Questionnaire Screen

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Survey Introduction and Special Instructions
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Section 1: Communitywide Planning Efforts for Healthy Eating and Active Living Questions
Section 1: Page 1

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Section 1: Page 2

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Section 1: Page 3

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Section 1: Page 4

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Section 1: Section 1 Submission Screen

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Section 2: The Built Environment and Policies That Support Physical Activity Questions
Section 2: Page 1

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Section 2: Page 2

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Section 2: Page 3

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Section 2: Page 4

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Section 2: Page 5

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Section 2: Page 6

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Section 2: Page 7

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Section 2: Page 8

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Section 2: Page 9

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Section 2: Page 10

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Section 2: Page 11

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Section 2: Section 2 Submission Screen

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Section 3: Policies and Practices That Support Access to Healthy Food and Healthy Eating
Section 3: Page 1

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Section 3: Page 2

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Section 3: Page 3

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Section 3: Page 4

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Section 3: Page 5

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Section 3: Page 6

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Section 3: Page 7

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Section 3: Page 8

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Section 3: Page 9

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Section 3: Page 10

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Section 3: Page 11

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Section 3: Page 12

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Section 3: Page 13

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Section 3: Page 14

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Section 3: Page 15

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Section 3: Page 16

23A

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Section 3: Section 3 Submission Screen

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Logout Screen

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