Youth Management Program Survey

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Please take a minute to complete the survey below. The purpose of this is to get your thoughts about a future youth (10 to 18 years old) weight management program we are developing. We plan to use this information as input to develop a nutrition, exercise, and health program tailored to meet the needs of youth in the Inland Empire. Thank you for your time and interest!

Please provide your personal information below, so we can reach out to you as soon as we have more information about California State University’s new program:

Your name: *

Preferred phone number: *

Preferred email: *

1 - How many youths (10 to 18 years old) do you know that could benefit from this type of program? 1, 2, 3, 4 etc. *

2 - If in-person, would you be willing to bring them to the CSUSB campus (when pandemic restrictions have been lifted) to participate in a structured weight management program? *

Yes

3 - Would you still consider this program if offered online? *

Yes

4 - How important is managing your teenager’s weight to you personally? Not at all important 🡪 Very important 0 1 2 3 4 5 *

0 (Not at all important)

5 (Very important)

5 - How important is weight management to your teenager? Not at all important 🡪 Very important 0 1 2 3 4 5 *

0 (Not at all important)

5 (Very important)

6 - Select the top 3 reasons you believe they have difficulty managing their weight. *

Eating because of emotions or stress

Family problems

Loneliness

Loss of loved one

Eating too much

Poor food choices or habits

Not getting enough physical activity

Difficulty with self-control

Hungry all the time

Loves to eat

Illness or injury

Medications led to weight gain

Other

None of the above

Required

7 - What do you think may get in the way of your teenager changing their eating habits, specifically? (select all that apply) *

Eating food from restaurants, fast food, convenience stores, vending machines

Too much high calorie food available at home

Too little time to prepare and eat healthy food

Too little money to buy healthy food

Feeling hungry much of the time

Used to eating a certain way

Difficulties such as stress or depression

Being with others who overeat

Don’t know how

Other

None

Required

8 - What do you think may get in the way of your teenager changing their physical activity habits? (select all that apply) *

Too little time/too busy

Safety concerns

No place to walk or be active

No transportation

Lack of support or encouragement from others

Difficulties such as stress, depression, etc.

Does not like to exercise

Daily habits or routines that do not include exercise

Pain/physical ailment

Too Tired

Other

None of these

Required

9 - Is there anything about a weight loss programs that worries you? *

Yes

10 - If you answered yes to the question above, please explain:

11 - How did you hear about us? *

Thank you again for your time and interest! We will contact you soon with updates regarding this program!!

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