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Hello:
You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
I am within the age bracket:
 
40-50
 
51-60
 
61-70
 
71-80
 
81-90
 
91+
 
Choose Not to Answer
 
 
 
I am a:
 
Male
 
Female
 
Choose Not to Answer
 
 
 
I am:
 
White
 
African American
 
Hispanic
 
Asian
 
Native American
 
Other
 
 
 
 
I consider myself fit enough to walk up a flight of stairs
 
Strongly Agree
 
Agree
 
Disagree
 
Strongly Disagree
 
 
 
I consider myself fit enough to walk up a flight of stairs with a basket of laundry
 
Strongly Agree
 
Agree
 
Disagree
 
Strongly Disagree
 
 
 
I consider myself fit enough to shovel snow/rake leaves
 
Strongly Agree
 
Agree
 
Disagree
 
Strongly Disagree