SeniorNutritionProgramSurvey 

TemplateforCurrentClients

Please take a moment to fill out this survey. Your answers and comments will help 

us serve you better.

1. How would you rate this meals program overall?

a. Excellent 

b. Very good

c. Good

d. Fair

e. Poor

2. Would you recommend this meals program to a friend?

a. Yes 

b. No

3. Do you eat healthier foods as a result of the meals program?

a. Yes 

b. No

4. Does eating meals from the meals program improve your health?

a. Yes 

b. No

5. Does the meals program help you to continue to live independently? (Are you 

able to stay living where you desire such as in your current community and 

home?)

a. Yes 

b. No

6. As a result of receiving meals, do you feel better?

a. Yes 

b. No
7. As a result of receiving meals, do you see your friends more often?

a. Yes 

b. No

8. Think about all the foods that you receive from the meal program. Please tell 

us how often you are satisfied with:

Always 

Satisfied

Usually 

Satisfied

Sometimes 

Satisfied

Seldom 

Satisfied

Never 

Satisfied

The taste of the 

meals 5 4 3 2 1 

The variety of the 

meals 5 4 3 2 1 

The smell of the 

meals 5 4 3 2 1 

The appearance of 

the meals 5 4 3 2 1 

9. The reasons I enjoy coming to the meal site are: (check all that apply)

a. Food

b. Friends/ Socialization

c. Services/ Activities at the site

d. Location

e. Welcoming atmosphere

f. Other (please fill in here):

10. How do you most often reach the meal site? (check all that apply)

a. Walk

b. Drive alone

c. Carpool

d. Bus/ Subway

e. Paratransit service

f. Taxi

g. Rideshare (Uber/Lyft)

h. Other (please fill in here):

11. What types of food would you like to see more often on the menu? (check all 

that apply)

a. Beef 

b. Chicken

c. Fish

d. Pork
e. Soups

f. Salads

g. Fruits

h. Vegetarian options (tofu, cheese, beans)

i. Other (please fill in here):

12. Are there other types of meals you would like us to serve, such as Indian, 

Latino, Chinese, halal meals, kosher meals, vegan/vegetarian meals, or 

others? Please specify:

13. Do you enjoy/value the additional services you receive at the meal program 

(nutrition education, blood pressure checks, bingo, karaoke, fitness classes, 

etc.)

a. Yes 

b. No

14. Do you have any suggestions for other services we could provide? Please 

specify: 

15. Do you have any other comments or feedback for us?

16. If you would like to subscribe to our online newsletter, please provide your 

email address:

Thank you for completing this survey!

(Sources: Santa Clara County Nutrition Program Survey; 16th National Survey of Older 

Americans Act Participants (NSOAAP))

This project was supported in part by grant number 90PPNU0002 from the Administration for Community Living, 

U.S. Department of Health and Human Services, Washington, D.C. 20201.

Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

Created in partnership with the National Association of Nutrition and Aging Services Programs. For more 

information on NANASP, visit nanasp.org.