(1) Gender: Male_____ Female_____

(2) Age: 18-25_____ 26-40_____ 41-50_____ 51-60_____ 60+_____

(3) Occupation Type: Faculty_____ Administration____ PAT(Professional/Technical)______Operating Staff_______

(4) Highest Level of Education: Doctorate____Masters____ Bachelors____

Two year degree____High School____Less than High School______

(5) Do you work? Full Time_____ Less than full-time_____

(6) Number of years employed at UNH: ______

(7) Are you insured through the University? Yes_____ No_____

(8) Are you interested in learning more about CHE? Yes_____ No____ If Yes, which services would interest you (check all that apply)

Dietary Analysis/Counseling______ Weight Management____

Metabolic Testing______ General Fitness Tests____

Blood Lipid/Glucose Analysis______ Pulmonary Function_____

General Allergy Screening______ Other (please specify)_____

If No, please check all that apply:

Services available elsewhere____

Have had similar tests______ Not interested_____

Don’t need services_____ Other (please specify)____

(9) Would using CHE services depend on whether or not the cost was covered by your insurer? Yes______ No______

Before 8AM____ Weekdays_______

8AM-11AM_____ Weekends_______

12-1PM_____

2PM-5PM_____

After 5PM ____

(11) Would you be more likely to participate in CHE if your family was eligible to receive this benefit? Yes_________ No__________

Spouse/Partner___ Preschool child___ Adolescent child___ Teenage Child____

Other relatives/family members____

_____________________________________________________________