Nutrition Area Plan 2019 Question Title * 1. Have you ever used SWIRCA & More services? Yes No Question Title * 2. If you answered yes to question #1, what services have you used? Meals Attend events Activity Center Information and referral Case Management Other (please specify) Question Title * 3. How do you stay informed about events happening in your community? Computer/websites Facebook Printed literature TV Newspaper Word of mouth Maturity Journal Other (please specify) Question Title * 4. Have you ever received a SWIRCA & More meal? Yes No Question Title * 5. How satisfied were you with the meal provided to you? Very Poor Poor Average Good Excellent N/A Question Title * 6. What additional variety of foods would you like to see offered on the SWIRCA menu? 1 2 3 4 Question Title * 7. What activities would you like to see offered at the meal sites (examples: book club, bingo, cards)? 1 2 3 Question Title * 8. Currently SWIRCA offers a lunch meal. If breakfast and/or dinner were offered would you be interested in attending? Yes No Breakfast Breakfast Yes Breakfast No Dinner Dinner Yes Dinner No Question Title * 9. When would you most likely participate in activities such as those provided by SWIRCA & More? 7 – 9 am weekdays 9-12 am weekdays 12-4 pm weekdays 4-8 pm weekdays 9-12 am Saturday Any weekend hours Question Title * 10. How often do you eat away from home (restaurants/family)? 2 times or less per week 3-5 times per week 6-8 times per week more than 8 times per week Question Title * 11. On average how many meals do you eat a day? One Two Three Question Title * 12. Do you feel you are able to eat a balanced diet? Yes No Question Title * 13. Do you feel you have enough money to purchase the foods you need to have a healthy, balanced diet? Yes No Question Title * 14. What does good nutrition mean to you? Question Title * 15. Where are you most likely to visit a meal site? Please rank as 1 being your top choice and 7 being your least favorite. 1 2 3 4 5 6 7 Activity Center 1 2 3 4 5 6 7 Restaurant 1 2 3 4 5 6 7 Union Hall 1 2 3 4 5 6 7 Club (elks, lions. etc.) 1 2 3 4 5 6 7 Church 1 2 3 4 5 6 7 Grocery Store 1 2 3 4 5 6 7 Apartment Building /Clubhouse Question Title * 16. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? Yes No Question Title * 17. In the last 12 months, have you ever had to go without health care because you didn’t have a way to get there? Yes No Question Title * 18. Are you worried that in the next 2 months, you may not have stable housing? Yes No Question Title * 19. What zip code do you live in? 1 Question Title * 20. What is your age range? Under 50 51 -60 61-70 71-80 81 or older Question Title * 21. Gender Male Female Other Question Title * 22. If willing, please share a story of how SWIRCA & More services have helped you Done
