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Senior Center Questionnaire

  1. Aging Services Logo

  2. 1. PREFERRED INFORMATION:

  3. 3. Have you taken this survey in the last 6 months?

  4. 4. What is your gender?

  5. 5. What is your race/ethnicity?

    Check all that apply:

  6. 6. What is your age?

  7. 7. Which senior center do you attend most often?

  8. 8. How did you hear about the senior center?

  9. # Yrs. / # Mo.

  10. PLEASE ANSWER THE REST OF THESE QUESTIONS FOR THE CENTER PROGRAMS THAT YOU ATTENDED IN THE LAST 6 MONTHS.

  11. 10. Which Senior Center programs have you participated in in the last 6 months?

    Check all that apply:

  12. 11. If you participated in a HEALTH APPOINTMENT, please check all that apply. If not, skip to the next question.

  13. 12. If you participated in an EXERCISE CLASS, please check all that apply. If not, skip to the next question.

  14. 13. If you participated in a HEALTH SCREENING, please check all that apply. If not, skip to the next question.

  15. 14. Overall, in the last 6 months, how helpful have Senior Center programs been to you?

  16. 16. Please let us know how much the Senior Center programs have contributed to improvements in your health and wellness.

  17. 17. Please indicate your feelings about the center.

  18. 18. How helpful are the volunteers who help run programs at the Center?

  19. THANK YOU FOR TAKING THIS SURVEY!

  20. Leave This Blank:

  21. This field is not part of the form submission.