Ageism: Prejudice or discrimination on the basis of a person’s age.

* 1. Your age:

* 2. Zip Code:

* 3. Sex

* 4. In our society today, in general, how do you feel?

* 5. Have you experienced ageism or a stereotyped behavior towards yourself because of your age?

* 6. Have you ever experienced ageist attitudes or discrimination in the workplace?

* 7. Have you experienced ageism or ageist attitudes/stereotypes from any of the following? (please check all that apply)

* 8. Overall, how do you think society today generally views older adults?

* 9. Do you feel seniors are being portrayed in the news media today as being more and more a burden on society?

* 10. How do you feel television shows and/or movies today portray older adults?

* 11. Have you ever been made to feel that you are a burden on your family?

* 12. How do you feel about your overall health?

* 13. Have you attended a presentation explaining what ageism is?

* 14. Your race/ethnicity:

* 15. Your yearly income:

Your answers above will NOT be identified with you publically.  Please provide the following.

* 16. Name:

* 17. Email:

* 18. Please send newsletter

* 19. Cell phone:

* 20. Other phone:

Thank you for your participation in this survey.