WHIWH Client Satisfaction Survey

Question Title

* 1. In terms of your sex/gender how do you identify?
(please select all that apply)

Male

Female

Transgender

Transsexual

Intersex

Other (please specify)

Question Title

* 2. Sexuality:

Heterosexual

Lesbian

Bi-sexual

Queer

Other (please specify)

Question Title

* 3. What is your postal code?

Question Title

* 4. What is your age group

1-17

18-24

25-34

35-49

50-64

65+

Decline to answer

Question Title

* 5. How long have you been using programs and services at Women's Health in Women's Hands CHC

1-5 years

6-10 years

11-15 years

16-20 years

20+ years

Question Title

* 6. Which of the following groups would you use to identify yourself?

Latin American

Afro Caribbean

African

South Asian

Black Canadian

African American

Indo Caribbean

Other (please specify)

Question Title

* 7. Please indicate the language(s) you are able to use.

	Speaking	Reading	Writing
English	English Speaking	English Reading	English Writing
French	French Speaking	French Reading	French Writing
Spanish	Spanish Speaking	Spanish Reading	Spanish Writing
Swahili	Swahili Speaking	Swahili Reading	Swahili Writing
Somali	Somali Speaking	Somali Reading	Somali Writing
Amharic	Amharic Speaking	Amharic Reading	Amharic Writing
Hindi	Hindi Speaking	Hindi Reading	Hindi Writing
Urdu	Urdu Speaking	Urdu Reading	Urdu Writing
Punjabi	Punjabi Speaking	Punjabi Reading	Punjabi Writing
Arabic	Arabic Speaking	Arabic Reading	Arabic Writing
Portuguese	Portuguese Speaking	Portuguese Reading	Portuguese Writing
Italian	Italian Speaking	Italian Reading	Italian Writing
Other	Other Speaking	Other Reading	Other Writing

Please specify what other lanaguage(s) you are able to use.

Question Title

* 8. What was your family's total income last year?

Less than $15,000

$15,000 to $24,999

$25,000 to $34,999

$35,000 to $44,999

$45,000 to $54,999

$55,000 to $64,999

$65,000 or over

Decline to answer

Question Title

* 9. What is your religion?

Buddhist

Muslim

Catholic

Christian

Hindu

None/Agnostic/Atheist

Other (please specify)

Question Title

* 10. What role does religion play in your daily life?

Religion plays a large role in my daily life

Religion plays some role in my daily life

Religion plays no role in my daily life

WHIWH Client Satisfaction Survey

1. Demographics

Information about you:

Question Title

* 1. In terms of your sex/gender how do you identify?
(please select all that apply)

Question Title

* 2. Sexuality:

Question Title

* 3. What is your postal code?

Question Title

* 4. What is your age group

Question Title

* 5. How long have you been using programs and services at Women's Health in Women's Hands CHC

Question Title

* 6. Which of the following groups would you use to identify yourself?

Question Title

* 7. Please indicate the language(s) you are able to use.

Question Title

* 8. What was your family's total income last year?

Question Title

* 9. What is your religion?

Question Title

* 10. What role does religion play in your daily life?

Question Title

* 11. Please specify any way we can better accommodate your religious or faith-based needs?

Question Title

* 12. How many people in your household are supported by this income?

Information about you:

Question Title

* 1. In terms of your sex/gender how do you identify?(please select all that apply)

Question Title

* 2. Sexuality:

Question Title

* 3. What is your postal code?

Question Title

* 4. What is your age group

Question Title

* 5. How long have you been using programs and services at Women's Health in Women's Hands CHC

Question Title

* 6. Which of the following groups would you use to identify yourself?

Question Title

* 7. Please indicate the language(s) you are able to use.

Question Title

* 8. What was your family's total income last year?

Question Title

* 9. What is your religion?

Question Title

* 10. What role does religion play in your daily life?

Question Title

* 11. Please specify any way we can better accommodate your religious or faith-based needs?

Question Title

* 12. How many people in your household are supported by this income?

* 1. In terms of your sex/gender how do you identify?
(please select all that apply)