### Retired and Senior Volunteer Program Survey
**Background information on volunteer service and hours served** 1. When did y ou begin volunteering with the Retired and Senior Volunteer Program ?

Month _____ Year

_____ 2. How man y da ys have y ou volunteered with the Retired and Senior Volunteer Program in the past month?

___ 0 day s

___ 1 or 2 day s

___ 3 to 5 day s ___ 6 to 10 day s ___ More than 10 day s 3. H ow much time total would y ou say you’ve volunteered with the Retired and Senior Volunteer Program i n the past month ___ 0 hours ___ 1

- 10 hours ___ 11

- 20 hours ___ Greater than 20 hours 4. How much time total would y ou say y ou’ve volunteered with the Retired and Senior Volunteer Program in the past ye ar ___ L ess than 50 hours ___ About 50 hours ___ Between 50 and 100 hours ___ About 100 hours ___ Between 100 and 200 hours ___ About 200 hours ___ More than 200 hours

**Volunteer Activities** 5. What ty

pes of activities do y ou do in y our service with the Retired and Senior Volunteer Program? [CHECK ALL THAT APPLY] ___ I provide companionship to or support other older adults or individuals with disabilities in staying in their own home. ( Ask 5a) ___ Iprovide companionship to or support to older adults or individuals with disabilities living in group care situations. ( Ask 5b) ___ Iwork with children or y ouths to build their academic skills (e.g. tutoring, assistance in classrooms, mentoring ). ( Ask 5c)___ Iwork with y outh or children to provide social support for children (e.g. comfort, and helping youn g mothers ) ( Ask 5d) ___ Iprovide basic educational services or support to adults. ( Ask 5e) ___ Iprovide support services and information to veterans and/or military families. ( Ask 5g) ___ Iwork to prepare for or respond to emergency events. ( Ask 5i) ___ Iwork with social service or volunteer agencies to build capacit y and/or support other volunteers. ( Ask 5j) ___ Iserve in other way s. ( Ask 5k )

5a. I am going to read a list of activities RSVP volunteers engage in when providing companionship to individuals staying in their own home. Please indicate if y ou h ave done any of these activities in the past month.

In the past month, have you Yes/No If yes, how man y hours in the last month Help ed clients with errands Help ed clients attend to personal and health care needs Help ed clients with jobs around the home Deliver ed meals to clients Mad e clothing for clients Provide d companionship Provide d information on health insurance or healthcare access Provide d translation services Provide d health education Help ed clients b y driving them places Assist ed the station with organizational, outreach, or technology

needs Provide d clients with companionship or emotional support Staffed hotline Developed/maintained community

gardens Distributed information Provided financial literacy Provided housing servicesDistributed food Collected food/Food pantry support Worked on Preventing Elder Abuse Provided Training & Coaching Distributed information Other (Specify): _____

5b. I am going to read a list of activities RSVP volunteers do when providing companionship and support to individuals with disabilities living in group care situations. Please indicate if you have done an y of these activities in the past month.

In the past month, have you Yes/No If yes, how man y hours in the last month Helped clients with errands Helped clients attend to personal and health care needs Helped clients with jobs around the home Delivered meals to clients Mad e clothing for clients Provided companionship Provided information on health insurance or healthcare access Provided translation services Provided health education Helped clients b y driving them places Assisted the station with organizational, outreach, or technology

needs Provided clients with companionship or emotional support Staffed hotline Developed/maintained community

gardens Distributed information Provided financial literacy Provided housing services Distributed food Collected food/Food pantrysupport Worked on Preventing Elder Abuse Provided Training & Coaching Distributed information Other (Specify): _____

5c. I am going to read a list of activities that RSVP volunteers ty pically do when helping children and y ouths improve their academic skills

. Please indicate if you have done any of these activities in the past month

.

In the past month, have you Yes/No If yes, how man y hours in the last month Provided assistance in classroom (including Head Start classrooms) Provided tutoring (in general, or in p ublic School or Faith

- Based school ) Provided mentoring in s chool or other community

settings Other (Specify): _____

5d. I am going to read a list of activities that RSVP volunteers ty pically do when providing social support for children. Please indicate if you have done an y of these activities in the past month

. In the past month, have you Yes/No If yes, how man y hours in the last month Provided c omfort to c hildren Cared for i nfants Helped y oung mothers Other (Specify): _____

5e. I am going to read a list of activities RSVP volunteers t ypicall y do when providing basic educational or other support to adults. Please indicate if you have done an y of these activities in the past month

.

In the past month, have you Yes/No If yes, how man yhours in the last month Built & r epair ed homes Provided assistance with housing search Built or a ssisting homes

- Habitat for H umanit y Provided Adult Basic Education/helped with GED/ Adult ESOL/ESL Provided assistance with VI TA Provided income tax tutoring Provided assistance with preventing elder a

buse Provided financial literacy

e ducation Other (Specify): _____

5g. I am going to read a list of activities RSVP volunteers t ypicall y do when providing services to veterans and/or military families

. Please indicate if y ou have done any of these activities in the past month

. In the past month, have you Yes/No If yes, how man y hours in the last month Provided assistance to a DOL VETS Program Provided s upport for Mental Health Access Provided s upport for Legal Assistance Access Participated in a ctivity supporting veterans with disabilities and older veterans Participated in a ctivity supporting veterans in rural communities Participated in Economic Opportunity

Activity that includes secure housing Assist ed veterans with transportation Assist ed with access to state and federal benefits Provided o ther community

- basedactivities that serve veterans and military families Participated in National Guard Volunteer Services Provided coaching/c ounseling Mentored military

connected children Provided referrals to services Other (Specify): _____

5 i

. I am going to read a list of activities RSVP volunteers t ypicall y do when preparing for or respond ing to emergency events

. Please indicate if y ou have done any of these activities in the past month

. In the past month, have you Yes/No If yes, how man y hours in the last month Created disaster k its Performed o utreach Set up Call Centers Staffed Call Centers Transported v ictims Set up s helter Staff s helter Provided Health/First Aid Services Distributed m eals Clearing Debris Renovating Housing Providing Housing Transition Support Cleared debris Renovated housing Provided housing transition support Provided counseling Participated in fire m itigation Participated in tornado/hurricane

m itigation Other Disaster Mitigation (Specify

_ ___________ Assisted with disaster preparedness Provided a ssist ance withr ecovery Other (Specify): _____

5j. I am going to read a list of activities RSVP ty pically do when assisting social service or volunteer agencies build capacity to support volunteers

. Please indicate if you have done an y of these activities in the past month

.

In the past month, have you Yes/No If yes, how man y hours in the last month Recruited v olunteers Managed v olunteers Trained v olunteers Garnered donations Provided s upport for Blood Drives Collected f

ood Food Pantry

Support Other (Specify): _____

5k. Are there any

activities that y ou did in the past month as a RSVP volunteer that I did not mention?
Other way s in the past month

(specify) Yes/No If yes, how man y hours in the last month

**Demographics** 6. In what month and year were you born?

a. Month 01. JAN 02. FEB 03. MAR 04. APR05. MAY 06. JUN 07. JUL 08. AUG 09. SEP 10. OCT 11. NOV 12. DEC 98. Don’t Know 99. Refuse

b. Year

_______________

9998. Don’t Know 9999. Refuse 7. Gender?

___ Male ___ Female

___ I p refer not to answer
8. Are you of Hispanic or Latino origin?

___ Yes ___ No ___ Iprefer not to answer 9. What is your race? Please select one or more.

___ White

___ Black or African American

___ Asian ___ Native Hawai ian or other Pacific Islander ___ Ame rican Indian or Alaska Native ___ Iprefer not to answer

10. What is your Veteran Status [Check all that apply]

___ None, not a veteran

___ Active duty

or Reserve Component

___ Military

famil y

___ Veteran

___ Family

of veteran

___ Don’t Know ___ Ip r efer not to answer11. What is the highest grade or y ear of school or y ear of college you completed? ___ 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 ___ Idon’t know

12. Are you currentl y married, with a partner as if married, separated, divorced, widowed, or never married? ___ Married ___ Have partner ___ Separated ___ Divorced ___ Widowed ___ Never Married ___ Other

**Other volunteer services** 13. How man y hours di d you spend per week in the past four weeks doing volunteer work for religious, educational, health

- related, or other charitable organizations, **not** including yo ur volunteer service with the Retired and Senior Volunteer Program ? ___ 0 hours per week ___ 1

- 10 hours per week ___ 11

- 20 hours per week ___ Greater than 20 hours per week

**Self efficacy** 1 4

. I can do just about an ything I reall y set m y mind to. Do you agree or disagree with this statement? If disagree: Do you

___ Strongl y disagree

___ Somewhat disagree or

___ Slightly

disagreeIf agree: Do you

___ Slightly

agree

___ Somewhat agree or

___ Strongl y agree 1 5

. I can do the things that I want to do. Do y ou agree or disagree with this statement? If disagree: Do you

___ Strongl y disagree

___ Somewhat disagree or

___ Slightly

disagree If agree: Do you

___ Slightly

agree

___ Somewhat agree or

___ Strongl y agree

**Social Loneliness** 1 6

. How much of the time do y ou feel that y ou are alone? Would you say oft en, some of the time, or har dl y ever or never [Check one ]

___ Often

___ Some of the time

___ Hardl y ever or never

___ Don’t know

___ I prefer not to answer 1 7

. How much of the time do y ou feel that y ou lack companionship? Would y ou say often, some of the time, or har dly ever or never [Check one]

___ Often

___ Some of the time

___ Hardl y ever or never

___ Don’t know

___ I prefer not to answer

**Emotional Loneliness** 1 8

. How much of the time do y ou feel that there are people y ou feel close to? Would you say often, some of the time, or har dl y ever or never [Check one ]

___ Often

___ Some of the time

___ Hardl y ever or never

___ Don’t know

___ I prefer not to answer1 9

. How much of the time do y ou feel that there are people y ou can turn to? Would y ou say

often, some of the time, or har dl y ever or never [Check one ]

___ Often

___ Some of the time

___ Hardl y ever or never

___ I d on’t know

___ I prefer not to answer

**Employment and Retirement** 20 . Are you working now, temporaril y laid off, unemployed and looking for work, disabled and unable to work, retired, a homemaker, or what? [Choose all that apply] ___ Working now ___ Unemploy ed and looking for work ___ Temporaril y laid off, on sick or other leave ___ Disabled ___ Retired ___ Homemaker ___ Other (Please Sp ecify) _____ ___ Idon't know ___ Iprefer not to answer 20 a. (If laid off) In what month and y ear were you laid off? Month _____ Year _____ 20 b. (If unemplo yed ) In what month and y ear did this period of unemployment start? Month _____ Year _____ 20 c. (If retired) In what month and y ear did y ou retire? Month _____ Year _____ 20 d. (If retired) Thinking back to the time you [partly/completel y] retired, was that something you wanted to do or something yo u felt y ou were forced into? [Check one] ___ Wanted to do ___ Forced into ___ Part wanted, part forced ___ Idon't know ___ Iprefer not to answer

**Volunteer Experience**21. Do y ou agree or disagree with this statement: My RSVP volunteer work is a good match for my skills ? If disagree: Do you ___ Strongl y disagree ___ Somewhat disagree or ___ Slightly

disagree If agree: Do you ___ Slightly

agree ___ Somewhat agree or ___ Strongl y agree 22. Do y ou agree or disagree with this statement : My RSV P volunteer work is interesting ? If disagree: Do you ___ Strongl y disagree ___ Somewhat disagree or ___ Slightly

disagree If agree: Do you ___ Slightly

agree ___ Somewhat agree or ___ Strongl y agree 23. Do y ou agree or disagree with this statement : My RSVP superviso r provides me with the support and information I need to serve ? If disagree: Do you ___ Strongl y disagree ___ Somewhat disagree or ___ Slightly

disagree If agree: Do you ___ Slightly

agree ___ Somewhat agree or ___ Strongl y agree

**Additional information about volunteer experience**  24. What else would y ou li ke us to know about your RSVP volunteer service?

25. I s there any

thing else y ou would like to let us know?