3 Independent Living Survey

­ ­­­

INDEPENDENT LIVING PERFORMANCE MEASURE SURVEY

OMB Control Number: [3045-XXXX]

Expiration Date: 10/31/2024

Thank you for taking the time to complete this survey. We would like to know how the AmeriCorps Seniors volunteer who has been assisting you has affected your life.

All information will be kept confidential; please do not disclose your name. You may choose not to answer a question.

This 1st question is about how many hours of service that you may have received in the past 4 weeks from your AmeriCorps Seniors volunteer.

Tell us how many TOTAL HOURS in a typical week you received services.

Here is an example of how Mrs. Jones would answer question #1:

Her AmeriCorps Seniors volunteer usually spends one hour on Monday with and two hours on Wednesday. Therefore, the total hours a week that she receives services is 3 hours a week.

1. In a typical week, my AmeriCorps Seniors volunteer is with me for

hours

Please turn the page for the questions 2-13

Because I Have a AmeriCorps Seniors volunteer …

	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree
… I feel less lonely.
… I feel I have close ties to other people.
… I am able to do the things I need to do.
… I am able to do most things I want to do.
… I am more satisfied with my life.
… I can remain living in my own home.
… I am able to get to the grocery store.
… I am able to get to medical appointments.
… I am able to take care of other necessary errands/appointments.
… I am eating regularly scheduled meals.
Overall, I am satisfied with my AmeriCorps Seniors volunteer.
Overall, the AmeriCorps Seniors Program has met my expectations.

250 E Street SW

Washington, D.C. 20525

202-606-5000/ 800-942-2677