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

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* 1. Your age:

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* 2. Zip Code:

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* 3. Sex

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

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

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

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

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

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

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

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

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

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

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* 14. Your race/ethnicity:

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* 15. Your yearly income:

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

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* 16. Name:

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* 17. Email:

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* 18. Please send newsletter

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* 19. Cell phone:

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* 20. Other phone:

Thank you for your participation in this survey.

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