Please take a few minutes to provide feedback about the CHAMPSS dining program offered at S & E Cafe, Green Bamboo and Henry’s Hunan.   Your responses to the survey questions are confidential and you will not be denied services based on your answers. Your feedback is welcomed. 

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* 1. Which of the following CHAMPSS restaurants have you eaten at since July 2019?  Please check all that apply.

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* 2. How often do you currently eat at a CHAMPSS restaurant?

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* 3. Please rate the meals and service you receive from S & E Cafe on each the following categories:  Skip this question if you did not eat at S & E Cafe.

  Excellent  Good   Need Improvement  Poor
Quality of the food
Variety of the menu
Appearance of the food
Temperature of the food
Customer service from restaurant staff

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* 4. If you checked “Needs Improvement” or “Poor” to any of the questions above, please explain why.

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* 5. Please rate the meals and service you receive from Green Bamboo on each of the following categories.  Skip this question if you did not eat at Green Bamboo.

  Excellent  Good   Need Improvement   Poor
Quality of the food
Variety of the menu
Appearance of the food
Temperature of the food
Customer service from restaurant staff

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* 6. If you checked “Needs Improvement” or “Poor” to any of the questions above, please explain why.

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* 7. Please rate the meals and service you receive from Henry's Hunan on the following categories.  Skip this question if you did not eat at Henry's Hunan.

  Excellent  Good   Need Improvement   Poor
Quality of the food
Variety of the menu
Appearance of the food
Temperature of the food
Customer service from restaurant staff

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* 8. If you checked “Needs Improvement” or “Poor” to any of the questions above, please explain why.

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* 9. Please rate the customer service you received from the program staff at Self-Help for the Elderly when you enrolled or re-enrolled in the CHAMPSS program.

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* 10. Do you review the nutrition education available on the CHAMPSS website?

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* 11. Please rate your agreement with the following statement:  The nutrition education information on the website helps me maintain and/or improve my health and well-being.

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* 12. If you marked “Disagree” or “Strongly Disagree”, please explain why.

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* 13. What nutrition education topics would you like to learn more about? Mark all topics you're interested in.

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* 14. Please rate your agreement with the following statements.  Because I participate in the CHAMPSS program...

  Strong Agree   Agree   Disagree   Strongly Disagree  
I eat more fruits and vegetables. 
I know where to get help with other concerns when I need it.  
I am able to live more independently.
I feel less isolated and/or more connected to my community.  

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* 15. Please rate your agreement with the following statements about the CHAMPSS website.

  Strong Agree  Agree  Disagree  Strongly Disagree 
The CHAMPSS website is user friendly.
It is easy to add meals to my account online.

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* 16. Demographic Information  

 Age  

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* 17. Gender  

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* 18. Race/Ethnicity

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* 19. Please share other comments, if any.

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