3 ET Get Active

Get Active Pre-survey
Introduction
EmPOWERED to Serve: Get Active PRE-Survey
Please answer the questions below before you begin the Get Active experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_______________________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_______________________________________
3. In which of the following geographic regions do you currently live?
a. Central Valley/Kern County, CA
b. Las Vegas, NV
c. Orlando, FL
d. Charlotte, NC
e. Indianapolis, IN
f. Central Ohio, OH
g. Houston, TX
h. Philadelphia, PA
4. Which gender do you most identify with?
a. Male
b. Female
c. Non-binary
d. Prefer to self-describe: __________
e. Prefer not to answer
5. Are you of Hispanic, Latino/a, or Spanish origin?
a. Yes
b. No
c. Prefer not to answer

6. What is your race? Please select all that apply.
a. Asian or Pacific Islander
b. Black or African American
c. American Indian or Alaskan Native
d. White or Caucasian
e. Other, please specify: ___________
f. Prefer not to answer
7. What is your age range?
a. 18-29
b. 30-44
c. 45-59
d. 60-69
e. 70-79
f. 80 or older
g. Prefer not to answer
8. What is the highest level of education you have completed?
a. Less than high school
b. Some high school
c. High school graduate or equivalent
d. Associate degree (such as AA, AS)
e. Bachelor’s degree (such as BA, BS)
f. Graduate degree (such as MBA, MS, MD, PhD)
g. Prefer not to answer
9. How many minutes of moderate-intensity physical activity should adults get each
week?
a. 45 minutes
b. 90 minutes
c. 150 minutes
d. 200 minutes
10. What percentage of adults currently get the recommended amount of physical
activity?
a. 20%
b. 30%
c. 50%
d. 60%
11. What is an example of a moderate-intensity physical activity?
a. Standing
b. Running
c. Stretching
d. Walking briskly

12. Please select the level that best represents your current confidence that you can do
the following:
Not at all
confident
Exercise for at least
150 minutes each
week
Set exercise goals
for myself
Be active and have
fun at the same
time

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Thank you for taking this survey. Your response has been recorded. We hope you enjoy
the EmPowered to Serve module.
Do not forget to take the post-survey after you finish the training!

Get Active Post-survey
Introduction
EmPOWERED to Serve: Get Active POST-Survey
Please answer the questions below after you complete the Get Active experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_______________________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_______________________________________
3. How many minutes of moderate-intensity physical activity should adults get each
week?
a. 45 minutes
b. 90 minutes
c. 150 minutes
d. 200 minutes
4. What percentage of adults get the recommended amount of physical activity?
a. 20%
b. 30%
c. 50%
d. 60%
5. What is an example of a moderate-intensity physical activity?
a. Standing
b. Running
c. Stretching
d. Walking briskly

6. After participating in the Get Active experience, please select the level that best
represents your current confidence that you can do the following:
Not at all
confident
Exercise for at least
150 minutes each
week
Set exercise goals
for myself
Be active and have
fun at the same
time

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

7. Please rate the overall quality of your experience with Get Active. Select your choice
below.
Excellent

o

Above
average

Average

o

o

Below
average

o

Poor

o

Undecided

o

8. How likely are you to recommend the Get Active experience to a friend, family
member, or co-worker? Select your choice below.
Very likely

o

Likely

Neutral

o

o

Unlikely

o

Very
unlikely

o

Undecided

o

9. Is there anything else you would like to learn more about that was not included in
this Get Active educational session? Please feel free to include any comments or
questions you might have.
_______________________________________________________________________
We thank you for your time spent taking this survey.
Your response has been recorded.