Form 0917-0036 Community Nutrition Gardening Survey

Community Nutrition: Gardening Presentation

Date ________________ TOPIC: ________________________________________

Age: __ 5 years and younger __ 18 – 34 years __ 65 years and older

__ 6 – 17 years __ 35 – 64 years

Gender: __ Male __ Female

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Unsure Agree Strongly

Disagree Agree

1. I would recommend Community Nutrition to my family and friends 1 2 3 4 5

2. Usually my health is good 1 2 3 4 5

3. I am sure I can take care of my own health (T’áá hwó ájít’éego) 1 2 3 4 5

4. The presenter/educator was knowledgeable about related gardening information 1 2 3 4 5

5. The space for the presentation was a good location for gardening presentation 1 2 3 4 5

6. What type of gardening do you do at home? (Please circle all that apply)

Corn field Home garden

Container garden Raised garden bed

Family garden Community garden

Other ___________________________

7. What gardening practice, if any, do you intend to actually use as a result of what you have learned in this class? ____________________________________________________________________________________

8. What would you like to learn more about in future gardening classes? ____________________________________________________________________________________

Comments/Suggestions: ___________________________________________________________________

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COMMUNITY NUTRITION STAFF ONLY

Presenter’s Name: ­­­­­­­­­­­­­­______________________________

Facilitator’s Name: ­­­­­­­­­­­­­­______________________________

__ Healthy Weight __ Food Accessibility __ Breastfeeding Rev. 03/7/17