Pre-program, self-assessment: Health Leaders Fellowship Program 2021
This survey was designed to capture your perspective on the various health topics covered in the Health Leaders Fellowship Program. Your answers will be kept confidential. We will ask you to complete a similar assessment at the end of the program. The results will be used for program planning and program evaluation. Thank you for your participation!
Sign in to Google to save your progress. Learn more
Toxic Chemicals: Please choose that which best matches your experience
Strongly disagree (1)
Disagree (2)
Neutral (3)
Agree (4)
Strongly Agree (5)
I am knowledgeable about toxic chemicals and their impacts on the environmental and human health.
I am comfortable speaking with family and friends about the health impacts of toxic chemicals.
I am comfortable presenting to my colleagues or community about the health impacts of toxic chemicals.
I am comfortable speaking with decision makers, such as state legislators, about the health impacts of toxic chemicals.
I am very interested in learning more about the health impacts of toxic chemicals.
Clear selection
Food Systems: Please choose that which best matches your experience
Strongly disagree (1)
Disagree (2)
Neutral (3)
Agree (4)
Strongly Agree (5)
I am knowledgeable about the industrial food system and its impacts on the environmental and human health.
I am comfortable speaking with family and friends about the health impacts of the industrial food system.
I am comfortable presenting to my colleagues or community about the health impacts of the industrial food system.
I am comfortable speaking with decision makers, such as state legislators, about the health impacts of the industrial food system.
I am very interested in learning more about the health impacts of the industrial food system.
Clear selection
Energy Production: Please choose that which best matches your experience
Strongly disagree (1)
Disagree (2)
Neutral (3)
Agree (4)
Strongly Agree (5)
I am knowledgeable about various types of energy production and their impacts upon human health.
I am comfortable speaking with family and friends about the health impacts of energy production.
I am comfortable presenting to my colleagues or community about the health impacts of energy production.
I am comfortable speaking with decision makers, such as state legislators, about the health impacts of energy production.
I am very interested in learning more about the health impacts of energy production.
Clear selection
Civic Engagement: Please choose that which best matches your experience
Strongly disagree (1)
Disagree (2)
Neutral (3)
Agree (4)
Strongly Agree (5)
I am comfortable writing a letter or email to a decision maker, such as a state legislator, regarding key health policy issues.
I am comfortable writing a press release, opinion editorial, or newsletter article on an environmental health issue.
I am comfortable advocating for public policy changes related to environmental health.
I am comfortable advocating for institutional policy changes related to environmental health.
I am comfortable organizing my peers to take action around an issue that impacts human or environmental health.
Clear selection
Scenarios
In this section, you are asked to describe how you might apply what you know about food systems, toxics, and energy to affect change. There are no right or wrong answers. Please note that "I don't know" is a completely acceptable answer.
You are interested in leading an effort within your institution that: ...
Clear selection
Consider your chosen problem area when answering the following questions.  What steps do you take to initiate these efforts?
Who do you include in these efforts?
You've identified an environmental health/public health problem within your community. You believe that the State Legislature needs to tackle this problem. Choose an example issue, and answer the following with this in mind.
How do you bring this issue to the attention of legislators?
How do you get your legislators to take action on this issue?
Who do you include in your efforts?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Ecology Center. Report Abuse