Survey - Stroke Support Group Online Registration Form 2011-2012

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Question - Required - Group Name

Please enter the group leader contact information - mailing address, email and phone number are for internal purposes only.

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

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Question - Required - Meeting Place - Name (e.g. Sr.Center, Hospital, Church, etc.)

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Question - Required - Meeting Place - Location (e.g. Floor, Room Name, etc.)

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Question - Required - Meeting Place - Address

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Question - Required - Meeting Place - City, State, Zip

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Question - Required - Phone Number (for more information - public)

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Question - Required - Email Address (for more information - public)

Question - Not Required - Website (if applicable)

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Question - Required - Meeting Day (e.g. 1st Thursday of the month)

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Question - Required - Meeting Time (e.g. 4-5:30pm)

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Question - Required - Meeting Frequency (e.g. 2x/month, weekly, etc.)

Group Activities:

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Question - Required - What does your group provide? Select all that apply.
Please make between 1 and 11 selections from the choices below.

	Supportive Discussions
	Group Therapy/Rehabilitation Sessions
	Phone Support
	Fundraising Activities
	Educational Programs
	Meeting Notice
	Social Opportunities
	Newsletter
	Community Outreach
	Transportation
	Visitation Opportunities
	Other

Question - Not Required - If you selected "other" above, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

Group Type:

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Question - Required - Which category (or categories) best describes your group?
Please make between 1 and 4 selections from the choices below.

	Online Group
	Inpatient Program Participants Only
	Outpatient Program Participants Only
	Open to anyone in the community
	Other

Question - Not Required - If you selected "other" above, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

Group Specialty:

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Question - Required - Which category (or categories) best describes your group?
Please make between 1 and 8 selections from the choices below.

	Aphasia
	Caregivers Only
	Caregivers and Survivors
	Children with Stroke
	Seniors Only
	Stroke and Head Injury
	Survivors Only
	Other

Group Data:

Please provide the following:

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Question - Required - Average attendance

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Question - Required - Average age

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Question - Required - Age range of members

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Question - Required - Average number that are males

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Question - Required - Average number that are females

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Question - Required - Average number that are survivors

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Question - Required - Average number that are caregivers

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Question - Required - Total number of members on your group list

Group Mailing List:

Please provide the following:

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Question - Required - How large is your mailing list?

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Question - Required - How often do you mail to your list?

Question - Not Required - If you selected "other" above, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

Geographic Group Data:

Please select the location that best describes your group.

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Question - Required - Where is your group located?
Please make between 1 and 2 selections from the choices below.

	Urban
	Rural
	Other

Group Leader Data:

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Question - Required - Is your support group leader a :

Question - Not Required - If you selected "other" above, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If your leader is a healthcare professional, what is their specialty?

(Maximum response 255 chars, approx. 5 rows of text)

Stroke Smart Magazine:

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Question - Required - Does your group receive the quarterly magazine Stroke Smart?

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Question - Required - Would you like your group to receive FREE copies of Stroke Smart?

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Question - Required - How many new members do you get each month? (We will use this number to determine how many magazines to send you.)

Educational and Research Programs:

Question - Not Required - Please check box if yes.

	Would you be interested in free web-based educational programs?
	Do you have access to equipment and the internet for web events?
	You are a healthcare professional, and are interested in learning more about our membership benefits, which include discounted materials.

Please indicate your group’s level of interest in information about the following:

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Question - Required - Seminars and educational opportunities for survivors and caregivers Not at all
Somewhat
Very interested

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Question - Required - Living with stroke Not at all
Somewhat
Very interested

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Question - Required - Travel for people with disabilities Not at all
Somewhat
Very interested

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Question - Required - New treatments for stroke Not at all
Somewhat
Very interested

Question - Not Required - Questions, Comments or Suggestions:

(Maximum response 255 chars, approx. 5 rows of text)

Special Events:

If you have a special event that you would like us to post on the website please submit it here.

Submitting this form indicates that you give National Stroke Association permission to post all data from this form on the National Stroke Association website (excluding those items marked for internal use only).

If you have any questions or concerns, please contact Valerie Siebert-Thomas at 303-754-0926 or by email at vsiebert-thomas@stroke.org.