ACAP Program Feedback Survey - SAMPLE

1. Please rate the program on each of the following items:

Space Cell	Strongly Agree	Agree	Disagree	Strongly Disagree
The ACAP program content was relevant to my needs.	The ACAP program content was relevant to my needs.: Strongly Agree	The ACAP program content was relevant to my needs.: Agree	The ACAP program content was relevant to my needs.: Disagree	The ACAP program content was relevant to my needs.: Strongly Disagree
The program was easy to understand.	The program was easy to understand.: Strongly Agree	The program was easy to understand.: Agree	The program was easy to understand.: Disagree	The program was easy to understand.: Strongly Disagree
The ACAP speaker was knowledgeable.	The ACAP speaker was knowledgeable.: Strongly Agree	The ACAP speaker was knowledgeable.: Agree	The ACAP speaker was knowledgeable.: Disagree	The ACAP speaker was knowledgeable.: Strongly Disagree
The ACAP speaker was responsive to questions.	The ACAP speaker was responsive to questions.: Strongly Agree	The ACAP speaker was responsive to questions.: Agree	The ACAP speaker was responsive to questions.: Disagree	The ACAP speaker was responsive to questions.: Strongly Disagree

2. How many ACAP programs have you attended (including in-person and virtual programs)?

• 1 (This was my first ACAP program)
• 2-4 programs
• 5+ programs

6. I am:

• Female
• Male
• Other
• Prefer not to answer

7. I am:

• Asian / Pacific Islander
• Black / African American
• Hispanic
• Native American

• White / Caucasian
• Biracial / Multiracial
• Race / Ethnicity not listed
• Prefer not to answer

8. I care for / am concerned about:  (Please check all that apply)
 

• Parent / in-law
• Spouse / partner
• Other relative
• Neighbor / friend

• Client / facility resident
• Information for my own aging
• Other