Intent to Change: Food Label - FY18

Information for site name and demographics (gender, age, etc) is NOT required. However, if you have this information please enter it. Otherwise skip to the ITC questions.

✻ = Required

County

Site name

Gender

Female Male

Age

60 or older 18-59

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino

Race

Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander White

Date

Curriculum/Educational Support Materials

If selected "Other", what curriculum/educational support materials were used?

The last time you shopped, did you use the "Nutrition Facts" on the food label to choose foods?✻

Yes No

The next time you go shopping, will you use the "Nutrition Facts" on the food label to choose foods?✻

Yes Maybe No

Please share with us how this workshop will help you and your family:

Comments