Form 1 Pre questionaire

OMB control number 0925-0634

Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0634). Do not return the completed form to this address.

Pre-Focus Group Questionnaire

1. How long have you been at your senior center?

• <1 year

• 1-5 years

• 5-10 years

• >10 years

2. Approximately, how many older adults belong to your senior center?

• <100

• 100-200

• 200-500

• 500-1000

• >1000

3. What is the average age of your members (this could also be a range of ages)?

• 60-65

• 65-70

• 70-75

• 75-80

• >80

4. What is the demographic (race, ethnicity, religion) makeup of your members?

5. Does you senior center have a budget for health information?

• No

• Yes. What is your budget: __________

6. Have you previously heard of the National Institute on Aging (NIA)? (If yes, please answer questions 7, 8 & 9; if no, please skip to question 10)

7. Does your center distribute/display any of NIA’s publications? If so, please list.

8. Do you use the NIA or NIHSeniorHealth.gov website? If so, for what purpose?

9. Does your center use any of NIA’s other resources? If so, please explain.

10. Does your center have a computer room?

• No

• Yes. Does your center offer computer training courses?

11. Does your center have health education or fitness courses?

• No

• Yes. Please describe:

12. Are you a senior residence as well as a senior center?

• No

• Yes