Adult-Education Activities Placemat

Feedback Form

Thank you for taking the time to provide us with your feedback.  We value your opinion and appreciate your help in this research.

Our mission at School For Seniors® is about elevating quality of life through PES™ (Purpose, Engagement & Socialization). Your contribution helps us to continue these efforts. Thank you!

Please fill out this feedback form after you have completed the adult-education activities placemat.

    My name is:

    My role is: SeniorFamily CaregiverCare PartnerOther

    My favorite lessons (please choose one or more): My StoryBrain TeaserWould You RatherMasterpiece of the DayGet InspiredSay Happy Birthday ToHumor of the DayBrain FoodGet CreativeWord Search

    Questions start HERE:

    1. Provided an opportunity to share my story? YesNo

    2. Made me feel like a student again? YesNo

    3. Was fun to do? YesNo

    4. Was thought provoking? YesNo

    5. Did I complete the lessons mostly by myself or with another person (for fun)?
    MyselfWith another person

    6. How did the activities make me feel: connectedproudchallengingall of the above

    7. Lessons were easy to read? YesNo

    8. I would recommend to a friend? YesNo

    9. I would like to contribute an idea or lesson? YesNo

    You can reach me about my feedback and suggestions.

    Best Number to reach me (phone):

    Email is okay (email):

    Best to send me a letter (address):

    Other thoughts or comments:

     

     

     

     

    WEEKLY SCHOOL FOR SENIORS® PLACEMATS EVALUATION

      Facility:    Date:

      Approx # of total placemats distributed:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total placemats distributed in room prior to meal:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total placemats in dining room prior to meal:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total participation in reading placemat:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total participation in answering questions on placemat i.e. writing answers on placemat:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total participation in discussing items on placemats with someone else:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Approx # of total placemats saved by senior:
      Monday | Tuesday | Wednesday | Thursday | Friday
      Saturday | Sunday

      Highlights - please give us your comments: