Keystone Empowers You (K.E.Y.)
In an effort to ensure our partner agencies have access to the most current information to make the best decisions about activities in the community, your answers to the following questions would be greatly appreciated.
How did you hear about this survey? *
What is your zip code? *
Community Outcomes
The next 3 questions are required to help track the outcomes of the K.E.Y. Collaborative.
On average, how many servings of fruits and vegetables do you consume each day? (A serving can include 1 cup of fruit or vegetables, 2 cups of leafy greens or 8oz of 100% fruit juice) *
During the last 7 days, how many times did you drink beverages containing sugar? (Include sodas, sweetened fruit drinks, sweetened fruit drinks mixed with alcohol, and energy drinks. Do NOT include 100% fruit juice, black coffee, unsweetened tea, or artificially sweetened beverages.) *
During the last 7 days, how many days did you engage in some type of physical activity for at least 30 minutes? *
Demographic Information
The questions below are not required. However; by providing this information, our partners are better able to analyze all reporting from across the community to ensure we are tailoring our activities correctly and reaching the population we intend to reach.
Your Gender
Clear selection
Your Age Range
Number of individuals in your household.
Clear selection
Household Income Range
If you would like to be added to the K.E.Y. email list, please provide your email address. Your contact information will not be shared or sold outside of the collaborative partners.
Never submit passwords through Google Forms.
This form was created inside of Lorain County Public Health. Report Abuse