SURVEY FORM
Your Name What is your nationality?AsianAmerican IndianBlack/African AmericanAfricanArab AmericanCaucasianHispanic/LatinoOther Your Gender: * Female/adult Female/teenager Male/adult Male/teenager Transgender Other Your Age Range * 12 to 18 19 to 26 27 to 40 41 to 65 66 to 80 81 to 95 96 to 100+ Which Ward/County/State do you live in? * Month/Year You Took The PIA Health Literacy Workshop? * Jan 2010 Feb 2010 Mar 2010 Apr 2010 May 2010 Jun 2010 Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011 Feb 2011 Mar 2011 Apr 2011 May 2011 Jun 2011 Jul 2011 Aug 2011 Sep 2011 Oct 2011 Nov 2011 Dec 2011 Where did you attend PIA's Health Literacy Workshop? *Anacostia Public LibraryAngelsArthur Capper Senior IBowie CollegeBowie State UniversityBrookland Manor Comm. Ctr.CAG WomenCAHE/WDCCapital Towers Sr. Bldg.Central Garden Apt.CHSWCCongress Park Community CenterCulpepper Gardens Senior CenterDelta TowersFairlington Mills Senior CenterFrederick Douglass Community CenterMartin Luther King, Jr. LibraryMax Robinson Medical CenterMichigan Park Christian ChurchMickey Leland HouseMillwood TownhousesNortheast Public LibraryNorthwest 1 LibraryPark Naylor Community CenterP.G. Community CollegePleasant HomesPotomac GardensShaw Public LibrarySoutheast Public LibraryThomas CircleWalker JonesWashington Highlands Interim LibraryWSWCYWCA Did you have computer skills before attending PIA's Health Literacy Workshop? * Yes No Have you used the Internet to find health information since completing PIA's Health Literacy Workshop? * Yes No Would You Recommend PIA's Workshop To Others? * Yes No What Would You Like To See PIA Do Next?