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North Devon CAN Baseline Questions
"
*
" indicates required fields
Step
1
of
5
– Name & Relationship to the natural environment
0%
Participant name
*
First
Last
Participant Date of Birth
*
Day
Month
Year
Today’s date
*
Day
Month
Year
Relationship to the natural environment
Your connection with nature
*
Strongly disagree (1)
Disagree (2)
Mildly Disagree (3)
Neutral (4)
Mildly Agree (5)
Agree (6)
Strongly agree (7)
I always find beauty in nature
I always treat nature with respect
Being in nature makes me very happy
Spending time in nature is very important
I find being in nature really amazing
I feel part of nature
Please rate yourself against each statement by choosing the number that best applies to you, where 1 is Strongly Disagree and 7 is Strongly Agree
Level of physical activity
In the past 7 days, on how many days did you do a walk lasting at least ten minutes?
*
No walking
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How much time did you usually spend walking on each day that you did the activity?
*
Was the effort you put into walking usually enough to raise your breathing rate?
*
Yes
No
In the past 7 days, on how many days did you do a cycle ride?
*
No cycling
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How much time did you usually spend cycling on each day that you did the activity?
*
Was the effort you put into cycling usually enough to raise your breathing rate?
*
Yes
No
In the past 7 days, on how many days did you do a sport, fitness activity (such as gym or fitness classes), or dance?
*
No sport
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How much time did you usually spend doing sport/fitness on each day that you did the activity?
*
Was the effort you put into the sport/fitness usually enough to raise your breathing rate?
*
Yes
No
Mental Wellbeing
Below are some statements about feelings and thoughts. Please rate yourself against each statement by circling the answer that best applies to you for each question.
I’ve been feeling optimistic about the future
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been feeling useful
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been feeling relaxed
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been dealing with problems well
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been thinking clearly
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been feeling close to other people
*
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been able to make up my own mind about things
*
None of the time
Rarely
Some of the time
Often
All of the time
Individual Development
Please rate yourself by choosing the statement that best applies to you
I can achieve most of the goals I set myself?
*
Strongly disagree
Disagree
Mildly Disagree
Neutral
Mildly Agree
Agree
Strongly agree
Is this the first time you have completed a CAN registration form?
*
Yes
No
Any other comments about this project?
CAN consent
I have read and I am satisfied that I understand the CAN Data Consent
*
Yes
We need to collect some basic information about everyone taking part in CAN projects to ensure that we are reaching and helping the people it is meant to benefit. Your sharing of this information is voluntary, but will be very useful in helping us achieve our objectives. Active Devon only share personal information with the CAN partner delivering and evaluating the project in which you participate, for the sole purpose of supporting your effective and safe participation. Your personal data will only be used in accordance with our privacy notice which you can read at www.activedevon.org/Privacynotice
I agree to allow Active Devon and organisations involved in delivering the CAN project to hold my personal information on the basis stated in the CAN Data Consent
*
Yes
No
I am happy to be contacted by Active Devon with relevant information and opportunities
*
Yes
No
I agree to any photos and video footage of me to be used by Age UK Devon, Active Devon and any CAN partners for promotional purposes
*
Yes
No
I am happy to be contacted with the CAN follow up surveys
*
Yes
No
You will be contacted to complete a simple follow up survey on 3 occasions. This is so we can evaluate the project, understand how it helps you and make it better in the future. The responses are anonymised prior to analysis.
Open Water Swimming Disclaimer
Consent name
*
First
Last
Date of consent
*
Day
Month
Year
Signature
*
