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and Hhygienic. Please take some time and fill this short Feedback form. This form is also available on our Greenlime page on Face book if you would like to share it online with us. _________________________________________________________________________________________________________________ Questionnaire Your Name: ________________________________________________________________ Address: _________________________________________________________________ Telephone and email id: __________________________________________________________ Your Child's School Name: ________________________________________________________ Your Child's age: ______________ Are both Parents working? : Yes ______ No ______ Family structure: Nuclear Family _________ Joint Family _________________________________________________________________________________________________________________ Question 1: We have observed that generally parents have the following concerns when the child is away from them. Please tick the ones that are your concerns; also rank them on the basis of severity. Rank 1. My Child is prone to infections easily 2. Child might catch infection from someone else 3. Child would hold going to washroom till he comes back home. 4. Child does not wash hands properly before eating. 5. Child might not eat properly. 6. Will the child be served hygienic food? 7. Nutritional food availability for my child 8. Child being bullied by friends or others 9. Any other concerns _____________________________________________ Question 2: We have identified some common sources for the concerns about a child's health. Please help us identify if they are true foryou too. 1. Season change time Yes___ No___ 2. Sudden weather changes. Yes___ No___ 3. Unhygienic Public Washrooms Yes___ No___ 4. Unavailability of water and soap in some places. Yes___ No___ 5. Child's inclination towards junk food Yes___ No___ 6. Hectic schedule of the parents Yes___ No___ 7. Pressure to perform on the Child Yes___ No___ 8. Pollution and dust Yes___ No___ 9. Any others, please specify ________________________________________________________
Question 3: Mentioned below are some statements that might help resolve some of your concerns? Please let us know whether you Agree or Disagree on the same 1. Ensure that public places like school, play grounds, Agree__ Disagree__ Neither Agree nor Disagree__ and other extracurricular classes where the child goes maintain good level of hygiene. 2. Making sure my child eats nutritional homemade Agree__ Disagree__ Neither Agree nor Disagree__ food. 3. Build immunity of my child with some nutritional Agree__ Disagree__ Neither Agree nor Disagree__ health supplements. 4. Making sure child does regular physical exercises. Agree__ Disagree__ Neither Agree nor Disagree__ 5. Make sure that the child maintains proper personal Agree__ Disagree__ Neither Agree nor Disagree__ Hygiene. Question 4: For the statement -- ''Ensure that public places like school, play grounds, and other extracurricular classes where the child goes maintain good level of hygiene''. Please share with us if you are willing to make a difference! How you will make sure that the above happens in the surrounding of your child! Greenlime will make sure to act upon your ideas and help you make it happen! _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Thank you for your Valuable time!