APPENDIX A

CANADIAN CONGRESS FOR LEARNING OPPORTUNITIES FOR WOMEN

WOMEN'S LEARNING NEEDS SURVEY

  1. Name your county
 ______________________________________
  1. Name your county
 ______________________________________
  1. Is your community
  1. urban ( )
  2. rural  ( )

  1. Age:

  1. 20-29
  2. 30-39
  3. 40-49
  4. 50-59
  5. 60+
( )
( )
( )
( )
( )

  1. Marital status:

  1. single
  2. married
  3. separated
  4. divorced
  5. widowed
  6. other
( )
( )
( )
( )
( )
( )

  1. How many children do you have at home in the following age groups?

  1. pre-school 0 - 5 years
  2. elementary school 5 - 12 years
  3. junior/senior high 13 - 19 years
( )
( )
( )

  1. Highest level of school completed

  1. grade school
  2. Junior high school
  3. completed high school
  4. G.E.D. equivalency
  5. upgrading
  6. post secondary
  7. some university
  8. completed university
  9. post graduate
( )
( )
( )
( )
( )
( )
( )
( )
( )
 indicate grade completed ( )

  1. Are you currently employed? yes ( ) no ( )


  1. Are you currently receiving social welfare yes ( ) no ( )
    If yes

  1. municipal assistance
  2. family benefits
  3. U.I.C.
  4. pension
( )
( )
( )
( )

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