Form Center

2. How long have you been attending the Agawam Senior Center for lunch?*

   1. Less than 6 months
   2. 6 months - 1 year

   1. 1-2 years
   2. 2-5 years

   1. 5-10 years
   2. 10+ years
4. What is your age?*

   1. Less than 50
   2. 50-54
   3. 55-59

   1. 60-64
   2. 65-69
   3. 70-74

   1. 75-79
   2. 80-84
   3. 85-89

   1. 90-94
   2. 95-99
   3. 100+
6. In what town do you currently live?*

   1. Agawam
   2. Chicopee
   3. Enfield

   1. Feeding Hills
   2. Longmeadow
   3. Southwick

   1. Springfield
   2. Suffield

   1. West Springfield
   2. Other
8. Please specify
10. How many days per week do you typically attend the Agawam Senior Center?*

    1. 1 day
    2. 2 days

    1. 3 days
    2. 4 days

    1. 5 days
12. How many days a week do you typically eat lunch at the center?*

    1. 1 day
    2. 2 days

    1. 3 days
    2. 4 days

    1. 5 days
14. How many days a week does your primary meal come from the center?*

    1. 1 day
    2. 2 days

    1. 3 days
    2. 4 days

    1. 5 days
16. Please rate the overall quality of the meals:*

    1. Excellent

    1. Good

    1. Fair

    1. Poor
18. The hot meals are always served hot.*

    Please rate the how often this statement is true.

    1. 5 - Always
    2. 4 - Usually
    3. 3 - Sometimes
    4. 2 - Rarely
    5. 1 - Never
20. The Cold meals are always served cold*

    1. 5 - Always
    2. 4 - Usually
    3. 3 - Sometimes
    4. 2 - Rarely
    5. 1 - Never
22. What are your 2 favorite meals?*
24. What are your 2 least favorite meals?*
26. The staff are courteous and efficient.*

    1. 5 - Strongly Agree
    2. 4 - Agree
    3. 3 - Neutral
    4. 2 - Disagree
    5. 1 - Strongly Disagree
28. The time of service is appropriate and consistent.*

    1. 5 - Always
    2. 4 - Usually
    3. 3 - Sometimes
    4. 2 - Rarely
    5. 1 - Never
30. The meals served by the Agawam Senior Center meet my nutritional needs.*

    1. 5 - Always
    2. 4 - Usually
    3. 3 - Sometimes
    4. 2 - Rarely
    5. 1 - Never
32. The dining room is always clean*

    1. 5 - Strongly Agree
    2. 4 - Agree
    3. 3 - Neautral
    4. 2 - Disagree
    5. 1 - Strongly Disagree
34. How many servings of fruit do you usually eat?*

    One serving of fruit is one piece of fruit; one half cup chopped, cooked, or canned fruit; or 3/4 cup of juice.

    1. 0
    2. 1

    1. 2
    2. 3

    1. 4
    2. 5+
36. What nutritional information would you like to learn more about?
38. What would encourage you to attend the Agawam Senior Center more often?*

    1. Different Meals
    2. Transportation

    1. Different Activities
    2. Other
40. Please Specify
42. Overall, how would you describe your experience with the staff at the Agawam Senior Center?*

    1. Excellent

    1. Good

    1. Fair

    1. Poor
44. How likely are you to recommend our meals to a friend or family?

    1. 5 - Very likely
    2. 4 - Somewhat likely

    1. 2 - Somewhat unlikely
    2. 1 - Very unlikely
46. Are you aware that the meals provided are free of charge and that we suggest a $3 donation?*

    This donation helps to ensure the continuation of the program for future seniors

    1. Yes
    2. No
48. Ia m satisfied with the variation of the meals offered on a weekly basis.*

    1. 5 - Strongly Agree
    2. 4 - Agree
    3. 3 - Neautral
    4. 2 - Disagree
    5. 1 - Strongly Disagree
50. I am satisfied with the taste of the meals.*

    1. 5 - Strongly Agree
    2. 4 - Agree
    3. 3 - Neautral
    4. 2 - Disagree
    5. 1 - Strongly Disagree
52. I enjoy the presentation of the meals.*

    1. 5 - Strongly Agree
    2. 4 - Agree
    3. 3 - Neautral
    4. 2 - Disagree
    5. 1 - Strongly Disagree
54. Additional Comments
    Please leave any additional comments you may have for us.
56. Follow up from Staff
    If you would like a staff person to follow up with you to clarify any questions you may have, or to give further feedback please leave your name and number below.
58. First Name
59. Last Name
61. Phone Number
63. Email Address
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65. 1. Receive an email copy of this form.
66. Email address

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