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* 1. Which Senior Center 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. Household Composition. Do you live...

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* 6. How did you learn about our services at the center?

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* 7. How long have you been using services at this Senior Center?

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* 8. How often do you come to the Senior Center?

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* 9. How satisfied are you with the hours and days of operation of the Senior Center?

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

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* 11. Are you aware that you can make a donation toward our program if you wish?

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* 12. How would you rate the activities and services you receive at this Senior Center?

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* 13. What other activities would you be interested in that are not currently offered at this Senior Center?

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* 14. Overall, how satisfied are you with the programs and services offered by the Senior Center?

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* 15. Has your live changed in anyway since you started attending the Senior Center? If Yes, how?

  Most of the Time Sometimes Rarely
You are able to socialize more
You have something to look forward to
You are more physically active
You learn about benefits and services for senior citizens

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* 16. Do you eat meals at the center? If you check No skip questions 17 & 18.

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* 17. Are you satisfied with the....

  Always Sometimes Never
Food Taste
Food Smells
Food Appearance
Food Variety
Food Temperature
Food Service Time

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* 18. Write your comments on the Meal Service here:

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* 19. Are there any additional services and/or activities that you would like the center to offer?

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