Sage Upstate Info 2013

1.

SAGE Upstate Participants: Thank you for taking a few minutes to fill out this survey -- your responses will help us in so many ways. First, it will help us know more about who we are serving, and which programs might be more needed. Second, it will tell us who we are not serving, and where we need to do outreach. Finally, grantmaking agencies always ask for demographic information, and the more we can show about who we are serving, the greater the chances we will get support. Overall, this survey will tell us more about your unique needs so we can provide you with programs and services that are meaningful. Again, thank you so much -- Kim

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* 1. First, please provide us with your contact information.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. What is your sexual orientation?

Gay/Lesbian

Queer

Bisexual

Heterosexual

Other (please specify)

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* 3. What is your sex?

Female

Male

Intersex

Other (please specify)

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* 4. Do you identify as transgender?

Yes

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* 5. What is your ethnicity?

Hispanic

Non-Hispanic

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* 6. What is your race?

African American/African

Asian American/Asian

Native American

Multiracial

White

Other (please specify)

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* 7. When were you born?

Birthdate:

Date

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* 8. Are you currently in a relationship?

Yes

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* 9. Are you married?

Yes

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* 10. If you are in a relationship, please provide your anniversary date.

Month, date, and year:

Date

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* 11. Please provide us with your employment status.

Still working

Retired

Retired and working part time

Unemployed

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* 12. If you are retired, when did you retire?

(If uncertain, best guess):

Date

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* 13. Do you live alone?

Yes

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* 14. Do you have children?

Yes

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* 15. Do you have internet access?

Yes

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* 16. Do you have an email account?

Yes

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* 17. How would you prefer to be contacted by SAGE Upstate? Please indicate your preferences.

	Most preferred	Ok	Least preferred
Email	Email Most preferred	Email Ok	Email Least preferred
Home Phone	Home Phone Most preferred	Home Phone Ok	Home Phone Least preferred
Cell Phone	Cell Phone Most preferred	Cell Phone Ok	Cell Phone Least preferred

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* 18. Do we need to use discretion when contacting you at your home phone?

Yes

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* 19. Do we need to use discretion when contacting you on your cell phone?

Yes

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* 20. Can we recognize your birthday and/or anniversary date in update emails and the newsletter?

Yes

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* 21. Can we use photos of you taken at SAGE events in our newsletter and outreach materials?

Yes

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* 22. Would you rather have materials mailed to you in a plain envelope? (If you don't check yes, mailings may contain logo and other descriptive writing)?

Yes

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* 23. Are you a caregiver (provide assistance with daily activities) for a parent, partner, friend, or someone else?

Yes

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* 24. Do you require any of items listed below (check all that apply)?

Rides to SAGE events

Sign-language interpreter

Wheelchair access

Large Print

Audio versions of written materials

Other (please specify)

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* 25. Please list below any agency, organization, business or other group where you would like to see a SAGE Upstate training on LGBT aging issues held.

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* 26. How did you first learn about SAGE Upstate?

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* 27. Please check all the program areas that interest you.

Aging In Place/ Living Independently

Arts and Crafts

Caregiver resources and support

Computer and Work related

Dances, parties, social events

Daytime Programs

Exercise/ Fitness

Grief/ Bereavement

Group Trips/Social Outings

Health (screenings, presentations)

HIV Testing/ Safer Sex Info

Holiday Gatherings

Intergenerational

Outdoor Activities

Singles Events

Support/ Counseling/ Mental Health

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* 28. Please check all the areas where you would like to volunteer.

Events

Fundraising

Giving Rides to SAGE events

Lending Library

Mailings

Newsletter Delivery

SAGE Upstate Center/Office

Speakers Bureau

Other

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* 29. Please check all committees on which you would be interested in serving.

Events Committee

Membership Committee

Potluck Committee

SAGE Upstate Board

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* 30. Please check any special skills you have to offer.

Carpentry Skills

Legal Services

Fundraising Experience

Board Service

Database Skills

I would like to lead a group or teach a class on:

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* 1. First, please provide us with your contact information.

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* 2. What is your sexual orientation?

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* 3. What is your sex?

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* 4. Do you identify as transgender?

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* 5. What is your ethnicity?

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* 6. What is your race?

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* 7. When were you born?

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* 8. Are you currently in a relationship?

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* 9. Are you married?

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* 10. If you are in a relationship, please provide your anniversary date.

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* 11. Please provide us with your employment status.

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* 12. If you are retired, when did you retire?

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* 13. Do you live alone?

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* 14. Do you have children?

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* 15. Do you have internet access?

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* 16. Do you have an email account?

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* 17. How would you prefer to be contacted by SAGE Upstate? Please indicate your preferences.

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* 18. Do we need to use discretion when contacting you at your home phone?

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* 19. Do we need to use discretion when contacting you on your cell phone?

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* 20. Can we recognize your birthday and/or anniversary date in update emails and the newsletter?

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* 21. Can we use photos of you taken at SAGE events in our newsletter and outreach materials?

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* 22. Would you rather have materials mailed to you in a plain envelope? (If you don't check yes, mailings may contain logo and other descriptive writing)?

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* 23. Are you a caregiver (provide assistance with daily activities) for a parent, partner, friend, or someone else?

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* 24. Do you require any of items listed below (check all that apply)?

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* 25. Please list below any agency, organization, business or other group where you would like to see a SAGE Upstate training on LGBT aging issues held.

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* 26. How did you first learn about SAGE Upstate?

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* 27. Please check all the program areas that interest you.

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* 28. Please check all the areas where you would like to volunteer.

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* 29. Please check all committees on which you would be interested in serving.

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* 30. Please check any special skills you have to offer.

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* 31. Thank you for completing this survey. Is there anything else you would like to add?