3 Volunteer Survey

Appendix C: Senior Corps Volunteer Performance Measure Survey

OMB Control Number: 3045-0146 Expires:10/31/2015

Sponsoring Organization

This field must be completed by the project director or another representative from the sponsoring organization.

___________________ _________________

Organization Name Grant Number

Prior to administering the survey, the project director or another representative from the sponsoring organization should provide the following information to each volunteer:

Start Date: Month___________ Year______________

Instructions for the Volunteer: Thank you for taking the time to complete this survey. All information will be kept confidential; please do not disclose your name. You may choose not to answer a question.

1. Today’s date

_______________ ___ ____________

Month Day Year

2. When did you begin volunteering with the Foster Grand Parent Program/ The Senior Companion Program?

Month____________ and Year_____________

3. Age ___________

4. Genderⁱ

• Male

• Female

• I prefer not to answer

5. Do you consider yourself primarily ⁱⁱ

• White/ Caucasian

• Black/ African American

• American Indian or Alaskan Native

• Asian Native Hawaiian, or Pacific Islander

• Other

6. Do you consider yourself Hispanic or Latinoⁱⁱⁱ

• Yes

• No

• I don’t know

7. Veteran Status [Check all that apply]

• Active duty or Reserve Component

• Military family

• Veteran

• Family of veteran

8. What is the highest grade of school or year of college you completed^iv

• No formal education

• Grades 1- 11

• Grade 12 (High School Diploma or GED)

• Some College

• Associate’s Degree

• Bachelor’s Degree/ College Graduate)

• Some graduate school

• Completed a graduate/professional degree

• Other

• I don’t know

9. Are you currently married, with a partner as if married, separated, divorced, widowed, or never married? ^v

• Married

• Have partner

• Separated

• Divorced

• Widowed

• Never Married

• Other

10. How many hours did you spend per week in the past four weeks doing volunteer work for religious, educational, health- related or other charitable organizations, including your volunteer time with FGP, SCP, and/or RSVP? ^vi

• 0 hours per week

• 1- 10 hours per week

• 11- 20 hours per week

• greater than 20 hours per week
  
  

11. Please think about your life-as-a-whole. Taking all things together, how satisfied are you with your life-as-a-whole these days? [Check one box] ^vii

• Completely satisfied

• Very satisfied

• Somewhat satisfied

• Not very satisfied

• Not at all satisfied

12. Would you say your health is excellent, very good, good, fair, or poor? [Check one box] ^viii

• Excellent

• Very good

• Good

• Fair

• Poor

13. How much of the time do you feel that there are people you feel close to? [Check one box] ^ix

• Often

• Some of the time

• Hardly ever or never

14. How much of the time do you feel that you lack companionship? [Check one box] ^x

• Often

• Some of the time

• Hardly ever or never

15. How many of your friends would you say you have a close relationship with? ^xi

Please write a number in the box

Please indicate how much you agree or disagree about each of the following statements

16. I can do just about anything I really want to do ^xii

• Strongly disagree

• Somewhat disagree

• Slightly disagree

• Slightly agree

• Somewhat agree

• Strongly agree

17. I can do the things that I want to do ^xii

• Strongly disagree

• Somewhat disagree

• Slightly disagree

• Slightly agree

• Somewhat agree

• Strongly agree

18. How much difficulty do you currently have walking one block?^xiii

• None

• A little

• Some

• A lot

• Can’t do

• I Don't Know

• Refused

The following text and the associated foot notes above are for the convenience of the Senior Corps Evaluation Vendor only and will not appear on the final version distributed to grantees or volunteers:

HRS References http://hrsonline.isr.umich.edu/index.php?p=concord

i Core Section, Section A, MA008

ii Core Section, Section B MB091M

iii Core Section, Section B , B028

iv Core Section, Section B, MB014

v Core Section, Section B, MB063

vi Core Section, Section G, G086, G195-7

vii Core, section B, B000 Campbell et al (1976)

viii Core, section C, C001 Standard Survey Question

ix Core, section LB*, Q20a,i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

x Core, section LB*, Q20a,i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xi Core, section LB, Q23a,e Multiple sources

xii Core, section LB, Q23a,e

xiii Core, Section: G, MG003