EFFORTS Suggestion Box

Instructions

This is a suggestion box in the form of a survey. All questions suggested must be able to have a yes or no response in order to be a "graph" response to measure what portion of our members (in percentage of a pie or graph) participate or suggest a specific format or question.
Answer questions as they relate to you. For most answers, check the box(s) most applicable to you or fill in the blanks. We have started with some basic questions to learn more about you and your interests. At the bottom, you can add your own questions for a later survey.

Please provide the following:

First Name

Last Name

Phone

About You

Your Age

	36-45
	46-51
	52-57
	53-58
	58-63
	64-69
	70-75
	76-80
	80 or more

2.	Your Gender

	Male
	Female

3.	Where do you live?

	In a larger city.
	In a rural area.
	In a small town.

4.	Using a scale of 1-10, 10 being the highest score. Please select the description that best suits your condition and ability get around.

	10. Was early diagnosed and am still employed.
	9. Have had lung surgery/transplant and am now quite active.
	8. I am NOT on oxygen and on Disability, but can still go out by myself.
	7. I am ON oxygen and on Disability but can still go about by myself.
	6. I do get out, but need to get a helper for oxygen and such.
	5. Am on oxygen and require a wheelchair/motorized cart.
	4. Am at home pretty much and get out occasionally.
	3. Pretty much stuck at home, have a fulltime in home caregiver.
	2. I live alone and do have a parttime caregiver, but cannot get out much.
	1. None of the above, see Remarks.

5.	How much time do you spend on the computer?

	Very little
	1-2 hours per day
	2-4 hours per day
	4-6 hours per day
	6-10 hours per day
	More than 10 hours?
	Other (See Remarks)

Remarks:

7.	Do you "surf the net" for information?

	Yes
	No
	Not often
	Don' t know how

8.	Do you have a separate telephone line for your computer?

	Yes
	No

9.	Have you ever tried to do your own website?

	Yes
	No

10.	Do you have your own website?

	Yes
	No

11.	If so, what is the URL or address of your website?

	(Provide up to three responses.)

12.	Your current At Rest use of oxgyen is:

	2 LPM or less
	2 LPM or more
	Not Applicable

13.	If on Oxygen, have you been told that you CAN turn your oxygen up slightly if you are walking or exercising?

	Yes
	No
	N/A

About EFFORTS

14.	How do you view EFFORTS?

	As a Support Source
	As an Advocacy/Activist Source
	As an Educational Source
	More than one of the above

15.	How do you feel about writing letters?

	I enjoy those projects.
	Am willing to, but need help doing it.
	I cannot write them myself, but am willing to have people do them for me.
	Am not interested in writing letters at all.

16.	Do you belong to lists other than EFFORTS?

	Yes
	No

17.	If so, how many others?

	NA
	One
	Two
	Three
	More than Three

18.	Would you like to become more involved with EFFORTS?

	Yes
	Cannot at this time

EFFORTS Suggestion Box

Please provide the following:

About You

About EFFORTS

Suggested Questions New Survey