EmailMe Form - Community Health Assessment Survey

Community Health Assessment Survey

This study is being conducted to assess behaviors in relation to new social norms among people who engage in outdoor activities.

The survey log is very brief and will take only a few minutes to complete each week.

Please provide your responses based on the 7 day period starting on Day 1 of the week [Sunday] and ending on Day 7 [Saturday].

As a qualified participant you will remain anonymous for the duration of the study. Your log entries will be used in aggregate with all other participant responses and will not be associated with any individual participants.

Your participation is voluntary and by completing the log you are giving your consent to be included in this study.

You may withdraw from this study at any time by simply discontinuing your submission of survey logs.

There are no known negative effects for participating in this study.

Please enter your Participant ID.

If this is your first log entry, you will determine your unique Participant ID in the following way:

Your participant ID will be a unique series of any 10 characters that you choose. Make sure that the chosen ID allows you to remain anonymous by not using your name, date of birth or other info that could be used to easily identify you. Make sure that you write down this ID, as you will need to enter it each time you fill out this log. *
Enter Day 1 of the week [Sunday] that you are logging. *
MM / DD / YYYY
Your weekly log should provide information based on the 7 day period from Day 1 of the week [Sunday], through Day 7 [Saturday].

The date you enter in this field should always be Day 1 of the week you are logging, [Sunday].
Enter Day 7 of the week [Saturday], that you are logging. *
MM / DD / YYYY
Your weekly log should provide information based on the 7 day period from Day 1 of the week [Sunday], through Day 7 [Saturday].

The date you enter in this field should always be Day 7 of the week you are logging, [Saturday].
Gender *
Male
Female
Age *
18-35
36-55
56+
Do you have a medical condition that makes you ineligible for the Covid-19 Vaccination? *
Yes
No
Have you ever received any doses of the Covid-19 Vaccination? *
Yes
No
Have you contracted Covid-19? *
No
Yes - Prior to the date I started this study
Yes - Since my last Survey Log entry.
How often do you wear a mask when engaged in outdoor activities? *
Always
Occasionally
Never
Is your attitude toward everyday living circumstances different today than it was prior to March 2020? *
Yes - More positive
Yes - More negative
No - Not changed
SURVEY LOG

Which of the following outdoor activities did you engage in this week and how frequently? *

	1-3 days	4-6 days	7 days	None
Hiking/Camping/Backpacking/Caving
Paddling/Canoeing/Boating
Fishing/Hunting
Bycycling/Running/Jogging
Walking for Exercise
Gardening
Outdoor Chores [mowing/tending animals/yard work/etc]

Basic Physical Health: Please rate each attribute below in relation to what you would consider your usual level of Good Physical Health. CHOOSE ONLY ONE ANSWER FOR EACH ATTRIBUTE. *

	Much Lower than my usual level	Somewhat Lower than my usual level	At my usual level	Higher than my usual level	Much Higher than my usual level
Overall Physical Health
Strength
Sleep Quality
Clarity of Thinking
Weight
Breathing/Respiration

Basic Mental Health: Please rate each attribute below in relation to what you would consider your usual level of Good Mental Health. CHOOSE ONLY ONE ANSWER FOR EACH ATTRIBUTE. *

	Much Lower than my usual level	Somewhat Lower than my usual level	At my usual level	Higher than my usual level	Much Higher than my usual level
Overall Mental Health
Anxiety
Peace of Mind
Irritability
Patience
Adaptability
Stress
Compassion
Anger

Everyday Life Activities: Please rate each attribute below in relation to your experiences this week with new social norms. YOU MAY CHOOSE MORE THAN ONE ANSWER FOR EACH ATTRIBUTE IF APPLICABLE. *

	I was expected to comply	I did comply	I did not comply	No compliance was required	Did not engage in this activity
Mask wearing to go shopping
Mask wearing to work at my job
Mask wearing to receive healthcare
Mask wearing for recreational activities
Mask wearing to travel
Social distancing to go shopping
Social distancing to work at my job
Social distancing to receive healthcare
Social distancing for recreational activities
Vaccination required to go shopping
Vaccination required to work at my job
Vaccination required for recreational activities
Vaccination to travel

Was there any event that occurred this week that had a significant effect on your emotional state. If so, please describe below.
This is referring to any event such as family discord, current events, news reports or any other event that significantly affected your emotional state.
At any time this week, did you feel threatened, ostracized or uneasy for not complying to any of the new social norms such as Mask Wearing, Social Distancing, Vaccination? If so, please describe below.

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SURVEY LOG