Appendix D2_ETS Salt and Cardiovascular Risk

Salt and Cardiovascular Risk Pre-survey
Introduction
EmPOWERED to Serve: Salt and Cardiovascular Risk PRE-Survey
Please answer the questions below before you begin the Salt and Cardiovascular
Risk experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_________________________
3. In which of the following geographic regions do you currently live?
a. Central Valley/Kern County, CA
b. Las Vegas, NV
c. Orlando, FL
d. Charlotte, NC
e. Indianapolis, IN
f. Central Ohio, OH
g. Houston, TX
h. Philadelphia, PA
4. Which gender do you most identify with?
a. Male
b. Female
c. Non-binary
d. Prefer to self-describe: __________
e. Prefer not to answer
5. Are you of Hispanic, Latino/a, or Spanish origin?
a. Yes
b. No
c. Prefer not to answer

6. What is your race? Please select all that apply.
a. Asian or Pacific Islander
b. Black or African American
c. American Indian or Alaskan Native
d. White or Caucasian
e. Other, please specify: ___________
f. Prefer not to answer
7. What is your age range?
a. 18-29
b. 30-44
c. 45-59
d. 60-69
e. 70-79
f. 80 or older
g. Prefer not to answer
8. What is the highest level of education you have completed?
a. Less than high school
b. Some high school
c. High school graduate or equivalent
d. Associate degree (such as AA, AS)
e. Bachelor’s degree (such as BA, BS)
f. Graduate degree (such as MBA, MS, MD, PhD)
g. Prefer not to answer
9. Sodium intake for most adults should not exceed:
a. 1,500 mg/day
b. 2,300 mg/day
c. 3,000 mg/day
d. 3,500 mg/day
10. Which of the following is a benefit of reducing the amount of sodium in your diet?
a. Reduced risk of kidney disease
b. Reduced risk of high blood pressure
c. Reduced risk of stomach cancer
d. All of the above
11. For the average person, how much do processed, packaged, and restaurant foods
contribute to their sodium intake?
a. 30%
b. 50%
c. 70%
d. 90%

12. Please select the level that best represents your current confidence that you can do
the following:
Not at all
confident
Read a nutrition
label to find the
amount of sodium
in your food
Reduce your intake
of packaged,
processed, and
restaurant foods
Use salt
alternatives like
spices or herbs
when cooking

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Thank you for taking this survey. Your response has been recorded. We hope you enjoy
the EmPowered to Serve module.
Do not forget to take the post-survey after you finish the training!

Salt and Cardiovascular Risk Post-survey
Introduction
EmPOWERED to Serve: Salt and Cardiovascular POST-Survey
Please answer the questions below after you complete the Salt and
Cardiovascular experience.
The survey should take less than 1 minute to complete. Your answers are completely
confidential and will only be used to improve future EmPowered to Serve trainings and
education.
Survey Questions
1. Please enter the first two letters of your birth month.

For example, if you were born in November, enter ‘NO’.
_________________________
2. Please enter the last three digits of your cell phone number.

For example, if your phone number is 214-763-9805, enter ‘805’.
_________________________
3. Sodium intake for most adults should not exceed:
a. 1,500 mg/day
b. 2,300 mg/day
c. 3,000 mg/day
d. 3,500 mg/day
4. Which of the following is a benefit of reducing the amount of sodium in your diet?
a. Reduced risk of kidney disease
b. Reduced risk of high blood pressure
c. Reduced risk of stomach cancer
d. All of the above
5. For the average person, how much do processed, packaged, and restaurant foods
contribute to their sodium intake?
a. 30%
b. 50%
c. 70%
d. 90%

6. After participating in the Salt and Cardiovascular Risk experience, please select the
level that best represents your current confidence that you can do the following:
Not at all
confident
Read a nutrition
label to find the
amount of sodium
in your food
Reduce your intake
of packaged,
processed, and
restaurant foods
Use salt
alternatives like
spices or herbs
when cooking

A little
confident

Somewhat
confident

Mostly
confident

Totally
confident

Not
applicable

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

7. Please rate the overall quality of your experience with Salt and Cardiovascular Risk.
Select your choice below.
Excellent

o

Above
average

Average

o

o

Below
average

o

Poor

o

Undecided

o

8. How likely are you to recommend the Salt and Cardiovascular Risk experience to a
friend, family member, or co-worker? Select your choice below.
Very likely

o

Likely

Neutral

o

o

Unlikely

o

Very
unlikely

o

Undecided

o

1. Is there anything you would like to learn more about that was not included in this
Salt and Cardiovascular Risk educational session? Please feel free to include any
comments or questions you have.
_______________________________________________________________________
We thank you for your time spent taking this survey.
Your response has been recorded.