KNOW MORE DO MORE

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General Information

First Name*

Last Name*

Address

Address line 1

Address line 2

City

Postal code*

Email address*

Telephone number *

Do you have children? *

yes no

If yes, please indicate the number of children and their age(s).

Where did you hear about the Know More Do More campaign? Select all that apply.
	Local public health unit
	Know More Do More website
	Friend/family member
	Campaign launch event
	Local newspaper
	Poster/flyer
	None of the above
	Other (Please specify)

The Champlain Cardiovascular Disease Prevention Network (CCPN) is looking to collect some information about the physical activity and eating behaviours of your family. This information will help to evaluate the effectiveness of the Know More Do More campaign and inform future program planning and service delivery to meet the needs of children and families in our region.

The CCPN respects your right to privacy. The information you share will only be used by the CCPN. For more information regarding the manner of collection, use and disclosure of personal information by the CCPN, please email ccpn@ottawaheart.ca.

Physical Activity Questions

As a parent/ caregiver, do you feel you have the necessary knowledge and skills to adopt and model physical activity behaviours, such as playing outdoors, for your children? yes no
In the past 7 days, have you done any of the following? Select all that apply.
	Played outdoors with your children
	Participated in family outings with your children, such as walking, hiking, biking
	Participated in activities with your children, such as dancing or recreational games
	Participated in a local physical activity program or class with your children
	Encouraged your children to spend more time engaged in physical activity
	Encouraged your children to spend less time watching TV or playing video/computer games
	None of the above
	Other (Please specify)

Healthy Eating Questions

As a parent/ caregiver, do you feel you have the necessary knowledge and skills to adopt and model healthy eating behaviours, such as cooking/ preparing healthier meals and snacks, for your children? yes no
In the past 7 days, have you done any of the following? Select all that apply.
	Provided healthy meals for your children according to Canada’s Food Guide
	Had healthier snacks available for your children according to Canada’s Food Guide
	Prepared home-cooked meals
	Educated your children about healthy foods
	Involved your children in meal planning /shopping/preparation
	Eating meals as a family, sitting together at the table
	None of the above
	Other (Please specify)

Tell Your Friends

I want to let my friends know about Know More Do More.
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