Protecting Our Health Member Survey | 1199SEIU Family of Funds

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Protecting Our Health
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Protecting Our Health Member Survey

Please complete this survey to receive your free copy of What’s Cooking — the first cookbook of healthy recipes for and by 1199SEIU members and retirees. All responses will be kept confidential (except for the one healthy tip that we ask you to share with other 1199SEIU members).

Member Survey

Please complete this survey to receive your free copy of What’s Cooking — the first cookbook of healthy recipes for and by 1199SEIU members and retirees. All responses will be kept confidential (except for the one healthy tip that we ask you to share with other 1199SEIU members).

Do you think that you are generally in good health or not?

Yes
No
Not Sure

'Do you think that you are generally in good health or not?' is required

Do you think you are overweight?

Yes
No
Not sure

'Do you think you are overweight?' is required

Do you exercise

Yes
No

'Do you exercise' is required

How often?

Once/week
2 times/week
3-4 times/week
5 times/week
Daily
More than daily

'How often?' is required

What kind of exercise?

'What kind of exercise?' is required

Do you have a chronic condition?

(Example: asthma, diabetes, hypertension, cancer, etc.)

Yes
No

'Do you have a chronic condition?' is required

If yes, what?

'If yes, what?' is required

Do you feel that you need to improve your health?

Yes
No
Not Sure

'Do you feel that you need to improve your health?' is required

If yes, what would you want to improve?

(SELECT ALL THAT APPLY TO YOU)

Eat a healthier diet
Be more physically active
Control my blood pressure
Monitor my blood sugar and keep it under control
Deal better with stress
Stop smoking
Get regular check-ups and cancer screenings
Lose weight

Other

'Other' is required

What would be the hardest thing to overcome to reach your goal?

'What would be the hardest thing to overcome to reach your goal?' is required
'What would be the hardest thing to overcome to reach your goal?' is required

Name

Title 'Title' is required

First Name 'First Name' is required

MI

Last Name 'Last Name' is required

Suffix

Home Address

Address 1 'Address 1' is required

Address 2

City 'City' is required

State / Province / Region 'State / Province / Region' is required

Postal Code 'Postal Code' is required
Postal Code is Invalid. Valid formats are xxxxx OR xxxxx-xxxx

Country 'Country' is required

Email

'Email' is required
Email is invalid

Phone

- ### 'Area Code' is required

- ### 'Exchange' is required

#### 'Phone' is required
Phone is invalid

Are you an 1199SEIU Member or Retiree?

Member
Retiree

Are you an 1199SEIU Staff Member?

Yes
No

If Yes, do you work for

Union
BPF
TEF
CCF

'If Yes, do you work for' is required

Where you work/worked

( 1199SEIU Institution)

'Where you work/worked' is required

Last four digits of your Social Security Number

'Last four digits of your Social Security Number' is required
'Last four digits of your Social Security Number' requires numeric input.

How did you hear about What's Cooking?

'How did you hear about What's Cooking?' is required

I would like to receive more information about the Benefit Fund's Protecting Our Health campaign

Is the above your Mailing Address as well?

Yes
No

'Is the above your Mailing Address as well?' is required

Your Healthy Tip

Add Instructions for this field.hare a tip for healthy living with other 1199SEIU members. (check the www.1199SEIUbenefits.org periodically! Your tip may go on the website!)

'Your Healthy Tip' is required
'Your Healthy Tip' is required

Thanks

Enter your employer's name to find your specific benefits information. If you are a retiree, click here.

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