Women in Transition HOPE Survey - page 1

INSTRUCTIONS: The purpose of this survey is to better understand your views and attitudes, helping us measure the overall impact of our program on the client population that we are serving. All responses will remain confidential and there is no obligation for you to take the survey, it is voluntary. It is important that you answer all of the questions, otherwise the survey analysis results could be invalidated. Please read each item and select the best response that reflects your answer.

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Date *

First Name *

Last Name *

City *

State *

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DEMOGRAPHIC INFORMATION

Age *

Educational Background *

Less than 12th grade
High School/GED
Technical
Some College
College Graduate

Race/Ethnicity *

White
Black or African American
American Indian
Asian
Hispanic or Latino
Other

WELL-BEING

Below are eight statements with which you may agree or disagree. Using the scale below, indicate your agreement with each item by indicating that response for each statement.

1. I lead a purposeful and meaningful life. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

2. My social relationships are supportive and rewarding. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

3. I am engaged and interested in my daily activities. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

4. I actively contribute to the happiness and well-being of others. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

5. I am competent and capable in the activities that are important to me. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

6. I am a good person and live a good life. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

7. I am optimistic about my future. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

8. People respect me. *

Strongly Disagree
Disagree
Slightly Disagree
Neither Agree nor Disagree
Slightly Agree
Agree
Strongly Agree

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