30%
Questions marked with an * are required Exit Survey
 
 
Name
   
 
 
 
Email Address *
   
 
 
 
Best Phone Number(s) *
   
 
 
 
Gender *
 
Male
 
Female
 
 
 
Age *
   
 
 
 
What best describes your ethnic background? *
 
White, or Caucasian
 
African-American
 
Asian or Pacific Islander
 
Native American
 
Hispanic
 
Hispanic mix (African American/Hispanic)
 
Other
 
 
 
Which of the following describes your employment status?
 
Self-employed full-time
 
Self-employed part-time
 
Employed full-time – 40 or more hours per week
 
Employed part-time
 
Full-time homemaker/Stay at home moms
 
Unemployed, looking for a job
 
 
 
What percentage of the HOUSEHOLD SHOPPING would you say that you, personally, do for your household? This includes household products as well as food items.
 
Under 25%
 
25% - 49%
 
50% - 74%
 
75% - 100%
 
 
 
Are you a caregiver for any adult age 55 or older who is struggling with aging or has a medical condition?
(By caregiver, we mean that you take care of someone who is unable to complete some daily tasks on their own. This care may include one or more activities such as managing medications, talking to doctors and nurses on someone’s behalf, helping to bathe or dress, taking care of household chores, meals or bills for someone who cannot do these things alone.)
 
Yes
 
No