Food Safety Feedback
University of Nebraska Cooperative Extension

        

Preventive Health
& Wellness Education
Feedback Form

 

Please take a moment to fill out the following form for each of your health, nutrition and wellness education program activities. Thank you! (NOTE: required responses are marked by *)

1. Your name: *

2. Your complete e-mail address:*
3. Name(s) of non-UNL Partners/Presentors:


4. District/Other: *

(Check ONE)
Northeast                                Panhandle
South Central Southeast
West Central Other
5. I did the following health, nutrition and wellness education actvity: *

(Check ONE)
ABC's Good Health: Steps for Health Sun Safety Education
ABC's Good Health: Build Healthy Base Online Diner Web Hits
Nutrition, Fitness and Youth Health Conferences
4-H Nutrition & Health Projects Health Fairs
Distributed NUfacts Health/Nutrition - Early Childhood Education
Promoted Cook It Quick Web site Community Lessons - Health/Nutrition
Promoted Other Web Sites Peer Nutrition Education
Answered Consumer Questions Tobacco Education
AgrAbility Cook It Quick Web Hits
Nutrition/Health/Wellness Media Other Web hits
Farm/Ranch Safety Camps Farm/Ranch Safety Activities Other than Camps
Other (describe)
6. Check type of group worked with: adults, youth or adults & youth: *
(Check ONE)
Adults Youth Adults & Youth

7. Approximate number reached by this health, nutrition or wellness education program activity: *

Adults:

Youth:

8. Was this a NEP program? *
Yes No

8. Briefly describe this activity, including impact if applicable: