This free survey is powered by QUESTIONPRO.COM
0%
 
 
Age
 
50-59
 
60-69
 
70-79
 
80-89
 
90 and Over
 
 
 
Gender
 
Female
 
Male
 
 
 
Race
 
Non-Minority
 
African American
 
Hispanic
 
American Indian
 
Native Hawaiian/Pacific Islander
 
Asian
 
Other
 
 
 
 
Household composition:
 
Alone
 
With your spouse
 
With your children
 
With other relatives
 
With non-relatives
 
 
 
How did you learn about our services
 
Brochure
 
Friend/relative
 
Media (TV,newspaper)
 
Church
 
Other
 
 
 
 
How long have you been using services at this center/focal point?
 
Less that 1 year
 
1-3 years
 
4-6 years
 
7 years and over
 
 
 
How often do you come to the senior center/focal point?
 
Less than once a month
 
1 to 3 times a month
 
1 time per week
 
2 to 4 times per week
 
5 times per week
 
 
How would you rate the services you recieve at this senior center/focal point?
Excellent Good Fair Poor N/A
Advocacy
Counseling
Congregate Meals
Education Programs
Information and Assistance
Transportation
Health Screening
Telephone Reassurance
Friendly Visiting
Health Promotion
Recreation
 
 
How would you rate the activities offered at the senior center?
Excellent Good Fair Poor N/A
Exercise Classes
Games
Arts & Crafts
Music/Dance
Field Trips
Computer Classes
Other Activities
 
 
 
What are the other activities?
   
 
 
 
How satisfied are you with the hours and days of operation of the senior center/focal point?
 
Very Satisfied
 
Satisfied
 
Dissatisfied
 
 
 
Do you find our staff courteous and professional?
 
Always
 
Usually
 
Sometimes
 
Rarely
 
 
 
Are you aware that you can make a donation toward our programs if you wish?
 
Yes
 
No
 
 
Has your life changed in anyway since you started attending the senior center/focal point?
Because of your participation at the center, do you feel that:
Most of the time Sometimes Rarely
You are able to socialize more
You have something to look forward to
You are more physically active
You learn about benifits and services for senior citizens
 
 
 
Overall, are you satisfied with the programs and services offered by the senior center?
 
Very Satisfied
 
Satisfied
 
Not Satisfied
 
 
 
How would you rate the quality of meals you get at the center?
 
Excellent
 
Very Good
 
Good
 
Fair
 
 
 
How would you rate the variety of meals you get at the center?
 
Excellent
 
Very Good
 
Good
 
Fair
 
 
 
How satisfied are you with the time the meal is served?
 
Very Satisfied
 
Satisfied
 
Not Satisfied
 
 
 
Write your comments on the meal service here:
   
 
 
 
Are there any additional services and/or activites that you would like the center to offer?
   
 
Please contact [email protected] if you have any questions regarding this survey.
Survey Software Powered by QuestionPro Survey Software