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0%
 
 
Age
 
60-64
 
65-69
 
70-74
 
75-79
 
80-84
 
85-89
 
90 and Over
 
 
 
Gender
 
Female
 
Male
 
 
 
Race
 
Black/African American
 
White
 
Hispanic
 
Asian
 
American Indian
 
Native Hawaiian/Pacific Islander
 
Other
 
 
 
 
How often do you eat meals offered at the nutrition site?
 
Once a month
 
Every week
 
Every day
 
 
 
How satisfied are you with the time the meal is served?
 
Very Satisfied
 
Satisfied
 
Not Satisfied
 
 
How would you rate
Excellent Very Good Good Fair
Variety of meals you get
Quality of meals you get
 
 
 
Always Most of the time Seldom
Is the hot food served hot?
Is the cold food served cold?
 
 
How would you rate
Excellent Very Good Good Fair Poor
Overall, meal service
Friendliness and courtesy of the staff
Building and Location
 
 
 
Are the donations you make kept confidential?
 
Yes
 
No
 
I don't contribute
 
 
 
What other services are provided at the Nutrition Site
 
Information about other services in the community
 
Physical Activity (Exercise)
 
Daily
 
Weekly
 
Monthly
 
Information about Medicare, Socail Security, Food Stamps, and other benifits

 
 
 
How do you get to the Nutrition Site?
 
I drive
 
My friend drives
 
Wheels
 
Other
 
 
 
 
How did you learn about the Nutrition Site?
 
Brochure
 
Church
 
Friend/Relative
 
Other
 

 
 
 
Additional Comments
   
 
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