ANNEX 4: PARTICIPANT INFORMATION FORMS
AGE FRIENDLY COMMUNITIES
PARTICIPANT INFORMATION FORM
Older People
Name:___ Phone:___
Address: ___ Postcode: ___
Please complete this Information Sheet by ticking the appropriate box or writing in your answer. We need this information so we can describe the characteristics of the people who took part in this age friendly planning consultation.
Age at last birthday: _____
Sex: ☐ Male ☐ Female
Present employment status:
Work Part-time ☐ Unemployed
☐ Retired ☐ Work Full-time
Present occupation or last major occupation: ___
How would you describe your current health?
☐ Excellent ☐ Good ☐ Fair
] Excellent □ Good □ Fair
Do you have any health problem that limits your ability to do your normal daily activities?
☐ Yes ☐ No
What is the highest level of schooling you completed?
□ Primary School
□ Secondary School
Technical or further
educational institution
(e.g. TAFE)
□ University or higher
School
Technical or further educational institution (e.g. TAFE)