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* 1. Which ADC do you attend?

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* 2. Age

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* 3. Gender

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* 4. Race

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* 5. How did you first learn about our program?

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* 6. How many days per week do you attend ADC?

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* 7. How long have you attended ADC?

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* 8. Reasons for attending ADC, Please check all that apply

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* 9. Do you feel your level of social interaction has significantly increased since you started attending the ADC?

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* 10. How satisfied are you with the current days and hours of operation of our facility?

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* 11. Please Rate the Following....

  Excellent Good Fair Poor Do Not Use It N/A
How would you rate the variety of activities offered at the ADC?
How would you rate the quality of activities offered at the ADC?
If center transportation is available, how would you rate it?
What rating would you give the ADC programming in meeting your current needs?
How are we doing in helping you meet your goals through using our services?

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* 12. How satisfied are you with the meals served at the ADC?

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* 13. Do you find our staff courteous and professional?

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* 14. How would you rate the ADC's communication in informing you of policies, event, news, etc.?

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* 15. Based on your experience at the ADC, would you recommend it to other seniors?

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* 16. Overall, how satisfied are you with the services/programs offered at the ADC Center?

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* 17. If you are the caregiver for the ADC participant, has the service been beneficial to you?

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* 18. If YES, please check all that apply

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* 19. Additional Comments

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