The Bruin Hibernation

Tuesday, December 15, 12-1p

Pardee Gym, JWC/8500 Boelter Hall/UCLA Extension, Rm 613/B01B LuValle Commons

Questions marked with an asterisk (*) are mandatory.
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* First Name
2

* Last Name
3

* Gender

Male
Female
4

* Department
5

* Email
6

* Please indicate Staff, Faculty, or Other

Question 7-11 are optional, however these questions are geared towards collecting data that will help to develop and improve FITWELL Programs for Faculty and Staff. Responses are confidential and will not be shared.
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Rate your present energy level at work on a scale of 1-5.
Very LowLowMediumHighVery High
8

Rate your ability to cope with daily stress at work on a scale of 1-5.

Very LowLowMediumHighVery High
9

How do you feel about your present physical condition in terms of overall health?

Very DissatisfiedDissatisfiedSomewhat SatisfiedSatisfiedVery Satisfied
10

In which of the following categories would you place yourself?

I am aware that physical activity will improve my heath, but I am disinterested.
I am interested in becoming more physically active to improve my health, but I am not currently physically active.
I am interested in becoming more physically active to improve my health, and I plan to start exercising in the near future.
I have recently become more physically active.
I have been physically active for less than 6 month.
I have been physically active for more than 6 months.
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How many times per week do you engage in physical activity? (Physical Activity= 30 min. or more of gardening, biking walking exercise class, etc.)

I am not currently physically active.
1-2 times per week
3-4 times per week
5 or more times per week

In order to complete your registration, Please read the following waiver (CLICK HERE) and indicate below you have read and understood this document.
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* I understand by agreeing, my signature is being transferred electronically, and I will not challenge the validity of the signature in any legal proceeding in which this document may be offered or used.