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?
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)
1 - 2 servings per day
3 - 4 servings per day
5 or more servings per day
0 - Do not like fruits and vegetables
0 - Can not afford fruits and vegetables
0 - Don't have access to fruits and vegetables
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.)
Not at all
1 - 3 times
4 - 6 times
1 per day
2 per day
3 per day
4 or more per day
During the last 7 days, how many days did you engage in some type of physical activity for at least 30 minutes?
5 or More Days
Not Able to Exercise
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 Age Range
Number of individuals in your household.
8 or More
Household Income Range
Less than $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
Prefer Not to Answer
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.
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This form was created inside of Lorain County Public Health.
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