Human Services Online Submission Forms

LYON COUNTY HUMAN SERVICES
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Congregate Meal Survey

  1. Lyon County - white background

  2. 620 Lake Avenue Silver Springs, Nevada 89429 ~ Phone: (775) 577-5009 Fax: (775) 577-5093

  3. Congregate Meal Survey*

  4. Senior Center*

  5. Your feedback is important to us, the information you provide will help us continue to strengthen our Senior Services programs. All responses are confidential, any identifying information you provide will be kept private and utilized for service enhancement.

  6. 1. How would you rate your health?*

  7. 2. How often are you sick?*

  8. 3. How often does your physical and/or emotional health interfere with your ability to attend to personal business, perform simple household chores, or participate in social activities?*

  9. 4. How would you rate your diet?*

  10. 5. Do you ever feel hungry?*

  11. If you answered “yes” to question 5, what would say is the reason(s)?

  12. 6. If you answered “yes” to this question previously, and “No” now, what has changed?

  13. (Optional)

  14. Leave This Blank:

  15. This field is not part of the form submission.