Questions marked with an * are required Exit Survey
Email Address *
Best Phone Number(s) *
Gender *
Age *
What best describes your ethnic background? *
White, or Caucasian
Asian or Pacific Islander
Native American
Hispanic mix (African American/Hispanic)
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.)