1.  Are you: 

Male   Female

2.  What is your age?

 Under 64    65 – 72    73 – 85    86 - 90
 91 – 93    94 – 96    97 +

3.  Are you:

Single    Divorced    Separated    Married 
 Widow(er)     Common-Law 

4.  You currently live in what type of residence?

 Rent home    Own home    Condominium    Lodge
Live with family    Senior Apartments    Other (Please specify)  

5.  You currently reside in which community?

 Barons    Coaldale   Coalhurst    Lethbridge
 Nobleford    Picture Butte    County of Lethbridge    Other (Please specify)  

6.  Yearly income is:

 Under $27,000    Over $27,000

7.  When would you start looking at retirement residences (for yourself or for a family member)?

 2007    2008    2009    2010
 2011    2012    2013 +

8.  Have you ever visited a seniors’ lodge?

 Yes    No

LODGE PERCEPTION

We want to identify your perceptions and feelings about retirement residences.  Please check one only.

1.  Are you aware of GAF (Green Acres Foundation)?

 Yes    No

2.  Are you aware that GAF is a not-for-profit organization?

 Yes    No

3.  Were you aware that GAF, a not-for-profit organization, is the only seniors’ housing provider in Lethbridge that targets low to moderate income seniors?

 Yes    No

4.  Do you know the difference between the level of services provided at a lodge, assisted living facility, enhanced assisted living (DAL) facility or nursing home?

 Yes    No

5.  What level of care would you relate with a retirement residence?

 Independent living with meals and housekeeping 
 Meals, housekeeping and personal care services 
 Meals, housekeeping and medical care