1. Where do you live? City: State:

2. Did you use the Web Site as a:
Member of the general public
Health service provider
Social service provider
Professional medical service provider

3. How did you find out about us?
Search Engine
Link from another site
A friend
Newspaper/radio/television
Display at an event
Trade show
Workshop
Academic/Trade publication
Other

4. What kind of information were you looking for? Please check all that apply.
Vision impairment
Aging-in-place assessment
Home modifications
O.T.

5. Did you find what you were looking for?
Yes
No

6. If yes, what were you looking for – please select all that apply.
Quick information/general information
More detailed information
Services information description:
Phone numbers
Mapped location of services
Other:

7. If no, what were you looking for that you could not find?  

8. Overall, how would you rate this site?
Excellent
Good
Satisfactory
Poor

USER INFORMATION
The following information is about the person who is in need of these services. It is completely anonymous and will only be used to help plan for the WEF web site. 

1. Were you searching for information for:
Yourself
Someone else

2. Is this person:
Male
Female

3. Is this person:
Married
Single
Separated/Divorced
Widowed
Married/Partnered

4. How old is this person?
Adult 18-44 years
Adult 45-64 years
Senior 65-84 years
Senior 85 + years

5. What is your level of vision impairment?
Low
Moderate
High

6. What are some of the most important concerns in your living environment or in your spiritual issues today?

7. What would be your combined family income?
Less than $12,000
Less than $25,000
$25,000 to $50,000 year
$50,000 to $75,000 year
Would rather not answer

Thank you for your time in completing this form.