Services - Dispenser's Section: Survey Form

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Dispenser's Survey

We will use the results from this Dispenser's Survey to enhance our services. Your cooperation is appreciated. If you wish to receive a free calendar (11" X 17" ) please indicate so at the end of the survey. You only need to provide your name and shipping information if you want the free calendar. If you have any questions please let me know how to reach you. Thanks.

1. Are you already a "Volunteer CCTV Dispenser"?	Yes	No
2. Have you recently dispensed a Reliant CCTV?	Yes	No
3. Will you be dispensing a CCTV within the next six months?	Yes	No
4. Are you a Lions member?	Yes	No
5. Did you take the online training?	Yes	No
6. Did you get your free "Volunteer CCTV Dispenser" lapel pin?	Yes	No
7. Does the online training adequately prepare you to dispense CCTVs?	Yes	No
8. Was your client satisfied with your services?	Yes	No
9. Was your experience personally satisfying?	Yes	No
10. Would you like to perform these services again?	Yes	No
11. Do you know that a $50 donation, in your client's name, would be made to the Lions Club of your choice?	Yes	No
12. Would your club be interested in proactively serving people, with low vision, through this Volunteer CCTV Dispenser opportunity?	Yes	No
13. Do you need promotional material?	Yes	No
14. Would you recommend this Volunteer CCTV Dispensing services, fund raising activity, to other Lions Clubs?	Yes	No
15. Would your club like to view a 15 minute video about how people, effected by macular degeneration, use CCTVs to stay independent?	Yes	No
16. Do you know that people 50 years or older get $100 off the Reliant CCTV list price?	Yes	No
17. Do you know that nearly everyone with an internet connection could be an Affiliate?	Yes	No
18. Do you understand why our "Volunteer CCTV Dispensers" are not permitted to become Affiliates?	Yes	No
19. Was this site easy to use?	Yes	No
Do you want someone to contact you?	Yes	No
If so, please provide your phone #:
... or your email address:
Do you want a free 11" X 17" calendar?	Yes	No
If so, please provide your name and shipping address below
Name:
Address:
City:
State:
Zip:

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