Form Center

2. 
4. 1. PREFERRED INFORMATION:
5. Today's Date (xx/xx/xxxx)
6. Initials of First & Last Name
7. Date of Birth (xx/xx/xxxx)
9. 2. If you would like to receive information from the Senior Center electronically, please provide your email. OPTIONAL
11. 3. Have you taken this survey in the last 6 months?

    1. NO or NOT SURE -continue
    2. YES-stop, return survey to staff
12. 4. What is your gender?

    1. Male
    2. Female
    3. Other
13. 5. What is your race/ethnicity?

    Check all that apply:

    1. American Indian/Native Alaskan
    2. Asian
    3. Black or African-American
    4. Hispanic/Latino
    5. Native Hawaiian/Other Pacific Islander
    6. White
    7. Other
15. 6. What is your age?

    1. 54 or below
    2. 55 to 59
    3. 60 to 69
    4. 70 to 79
    5. 80 to 89
    6. 90 & over
16. 7. Which senior center do you attend most often?

    1. Passmore (Hillsborough)
    2. Seymour (Chapel Hill)
18. 8. How did you hear about the senior center?

    1. Brochure
    2. Friend/Family
    3. Internet
    4. Newspaper
    5. Senior Times
    6. Other (see 8a)
19. 8a. If you selected "other," how did you hear about us?
20. 9. How long have you participated in our programs?
    # Yrs. / # Mo.
22. PLEASE ANSWER THE REST OF THESE QUESTIONS FOR THE CENTER PROGRAMS THAT YOU ATTENDED IN THE LAST 6 MONTHS.
24. 10. Which Senior Center programs have you participated in in the last 6 months?

    Check all that apply:

    1. Cultural / Performing Arts: dance, theater, music
    2. Education: aging seminars, arts and crafts, computer classes, financial management, health insurance / Medicare, language classes, legal counseling, tax assistance
    3. Health / Wellness: appointment, education, exercise, fitness room, screening
    4. Meals or snacks
    5. Recreation, games, sports
    6. Social events, Bingo, films, potlucks, receptions, trips, etc.
    7. Volunteer
26. 11. If you participated in a HEALTH APPOINTMENT, please check all that apply. If not, skip to the next question.

    1. Fit Feet
    2. Massage
    3. Reflexology

    1. Reiki
    2. Wellness Clinic

    1. Trager
    2. Other (see 11a)
27. 11a. Please specify "Other" Health Appointment.
29. 12. If you participated in an EXERCISE CLASS, please check all that apply. If not, skip to the next question.

    1. Aerobics, Ageless Grace, Inspired Movement, Pacesetter, Sally’s Senior Workout, Silver Sneakers Classes, Sit to be Fit
    2. Balance, TBT Tone-Balance-Tighten
    3. Strength Training, Strength Training & Movement, Strong & Steady
    4. Pilates, Tai Chi, Chair/Gentle Yoga, Yoga
    5. NIA or Zumba
    6. Other (see 12a)
31. 12a. Please specify "Other" Exercise Appointment.
32. 13. If you participated in a HEALTH SCREENING, please check all that apply. If not, skip to the next question.

    1. Blood pressure
    2. Glucose/Cholesterol
    3. Hearing
    4. Physical Function
    5. Vision
33. 14. Overall, in the last 6 months, how helpful have Senior Center programs been to you?

    1. Very helpful
    2. Somewhat helpful
    3. Not at all
35. What has been most helpful about your involvement with the Senior Center?
37. 16. Please let us know how much the Senior Center programs have contributed to improvements in your health and wellness.
39. a. Physical health
    -- Select One --Helps a lotHelps a littleDoes not help this timeframeDoes not apply
40. b. Mental well-being, mood, outlook on life
    -- Select One --Helps a lotHelps a littleDoes not help this timeframeDoes not apply
41. c. Enjoyment of life
    -- Select One --Helps a lotHelps a littleDoes not help this timeframeDoes not apply
43. d. Activity level, energy
    -- Select One --Helps a lotHelps a littleDoes not help this timeframeDoes not apply
44. e. Social Life, people I have met
    -- Select One --Helps a lotHelps a littleDoes not help this timeframeDoes not apply
46. 17. Please indicate your feelings about the center.
48. a. The location made it easy for me to attend
    -- Select One --AgreeMixedDisagree
49. b. I feel at ease at the Center.
    -- Select One --AgreeMixedDisagree
50. c. I have learned new things that are useful to me.
    -- Select One --AgreeMixedDisagree
52. d. I am more likely to participate in other community activities.
    -- Select One --AgreeMixedDisagree
53. e. My ability to remain independent in my home has improved.
    -- Select One --AgreeMixedDisagree
54. f. I would recommend that others come to the Center.
    -- Select One --AgreeMixedDisagree
56. 18. How helpful are the volunteers who help run programs at the Center?
58. a. Front Desk
    -- Select One --Very helpfulSomewhat helpfulNot helpfulDo not know
59. b. Class Teachers
    -- Select One --Very helpfulSomewhat helpfulNot helpfulDo not know
60. c. Special Events
    -- Select One --Very HelpfulSomewhat helpfulNot helpfulDo not know
61. d. Health screenings
    -- Select One --Very helpfulSomewhat helpfulNot helpfulDo not know
63. 19. Please add comments about the center's programs or activities.
65. THANK YOU FOR TAKING THIS SURVEY!
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67. 1. Receive an email copy of this form.
68. Email address

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