Feedback Form:
Pedometer Lending Library Project
Step up and be counted
Let's get walking with a pedometer
Win a pedometer! We hope you enjoyed your
pedometer experience. To
enter into a monthly draw for a pedometer, please complete this form.
Your feedback will help us evaluate the program in terms of
helping to promote a healthy lifestyle.
1. Have you borrowed a pedometer from the library
before?
Yes No
2. How did you hear about the Ottawa Public library's pedometer lending
program?
Television
advertisement
Library
display
Word
of mouth
Other (please specify)
3. On a scale of 1-5, how easy was the pedometer to use?
Very easy 1 2 3 4 5 Very
difficult
4. Did you typically wear the pedometer
Daily
When
you walked / exercised
From
time to time
Only
when your routine changed
Rarely
5. What was your main reason for deciding to use a pedometer:
(select most important reason)
Weight
loss
Blood
pressure regulation
Heart
Problems
Desire
to be more physically active
Advice
of a doctor
Diabetes
control
Cholesterol
control
Not
sure - just curious
Other (please explain):
6. Did you use the Let's
Get Walking with a Pedometer booklet to track
the number of steps taken?
Yes
No
7. Did tracking your steps motivate you to increase the number of daily
steps you took?
Yes
No
8. Did the use of a pedometer help you to set a walking goal?
Yes
No
9. Were you able to increase your daily steps over the pedometer loan
period?
Yes
No
10. Did using a pedometer increase your awareness of your daily
physical activity?
Yes
No
11. How much do you feel wearing your pedometer helped or encouraged
you to become or remain active?
Not
at all
A
bit
A
moderate amount
A
lot
A
great deal
12. Would you borrow a pedometer form the library again?
Yes
No
Not
Sure
13. About how physically active would you say that
you are, compared to
others of the same age and sex?
Much
less active
Less
active
As
active
More
active
Much
more active
Don't
know
The next questions are used for classification purposes only. Please be
assured that your responses will remain completely confidential.
14. Please tell us your age?
Under
10
11-14
15-19
20-24
25-34
35-44
45-54
55-64
65
or older
15. Are you
Male?
Female?
16. What is your postal code?
17. Do you have any other general comments about walking with a
pedometer or being physically active?
Thank you for taking the time to complete this
survey!
If you wish to be included in the monthly draw to
win a
pedometer please complete the following. Please be assured that this
information will not be used for any other purpose:
Name:
Phone: 
|