Senior Programs at the London Muslim Mosque
The purpose of this survey is to collect information about the types of programs that seniors/older adults would like to see at the London Muslim Mosque (LMM). Please answer as best you can for yourself or for another older adult.

This information is part of a project involving six Masters of Occupational Therapy students from Western University. All information will remain anonymous and will only be shared with the Imam for the purposes of program development.

1a. Who are you responding for? *
1b. If you are responding for someone else, what is your relationship to him/her? Please answer the rest of the questions from his/her point of view!
Your answer
2. Age *
Your answer
3. Gender *
4a. Which languages are you comfortable communicating in? *
Required
4b. If you specified a language above, please type it here:
Your answer
5. Which of the following activities do you participate in, during a normal week? Check all that apply. *
Required
6. Do you participate in any other senior programs and if so, where? *
Your answer
7. If not, why are you not participating in other senior programs around London?
Your answer
8. Which of the following are important to you in a programmed activity? Check all that apply. *
Required
9. Do you experience difficulties/challenges with the following areas? Please specify why. *
Required
10a. Do you have any accommodations that would help you participate in a program at the London Muslim Mosque? Please specify. For example, hearing aids, walkers, wheelchairs, sign language, etc. *
10b. If you said Yes above, please specify here:
Your answer
11. What time of the week would you be most available to participate in activities at the London Muslim Mosque? *
Required
12. If you were to participate in an activity at the London Muslim Mosque, how would you get there? *
Required
13. How many times a month would you like to participate in an activity for seniors? *
Your answer
14. Do you feel that the LMM is meeting all of your needs? If not, what are your ideas for more programs that you would enjoy? *
Your answer
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