Form 0917-0036 Community Nutrition Gardening Survey

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

2017 Community Nutrition Gardening survey new

IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition

OMB: 0917-0036

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Community Nutrition: Gardening Presentation

Date ________________ TOPIC: ________________________________________


Age:
__ 5 years and younger __ 18 – 34 years __ 65 years and older

__ 6 – 17 years __ 35 – 64 years

Gender: __ Male __ Female

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Unsure Agree Strongly

Disagree Agree


  1. I would recommend Community Nutrition to my family and friends 1 2 3 4 5

  2. Usually my health is good 1 2 3 4 5

  3. I am sure I can take care of my own health (T’áá hwó ájít’éego) 1 2 3 4 5

  4. The presenter/educator was knowledgeable about related gardening information 1 2 3 4 5

  5. The space for the presentation was a good location for gardening presentation 1 2 3 4 5

  6. What type of gardening do you do at home? (Please circle all that apply)

Corn field Home garden

Container garden Raised garden bed

Family garden Community garden

Other ___________________________

  1. What gardening practice, if any, do you intend to actually use as a result of what you have learned in this class? ____________________________________________________________________________________


  1. What would you like to learn more about in future gardening classes? ____________________________________________________________________________________


Comments/Suggestions: ___________________________________________________________________

***************************************************************************************

COMMUNITY NUTRITION STAFF ONLY

Presenter’s Name: ­­­­­­­­­­­­­­______________________________

Facilitator’s Name: ­­­­­­­­­­­­­­______________________________


__ Healthy Weight __ Food Accessibility __ Breastfeeding Rev. 03/7/17

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorTerrilynn.Johnson
File Modified0000-00-00
File Created2022-01-14

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