STARS US

1. Title Mr Mrs Miss Ms
2. Name of contact
3. I am a sufferer relative friend professional other (please specify)
4. I am (other)
5. Address line 1*
6. Address line 2
7. Address line 3
8. City*
9. State*
10. Postcode/Zip*
11. Telephone
12. Email address*
13. Name of sufferer (if different from above)
14. Sex Male Female
15. Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

For statistical and funding purposes only, would you please indicate in the appropriate boxes:

1. Household Income 10,000-50,000 50,000-100,000 100,000-250,000 250,000-500,000 500,000-above
2. Ethnic background for funding purposes only Caucasian African American Asian Hispanic Other (please specify)
3. Other
4. What information have you received from us?
5. Did you find this information Very helpful Helpful Unhelpful
6. Did it contain The right amount Too much Too little information
7. Did you find this information easy to understand? Yes / No
8. If no, please state why
9. Do you think anything should be added to this information? Yes / No
10. If yes, please state what
11. Do you think anything should be removed from this information? Yes / No
12. If yes, please state what
13. Have you received any other information relating to this subject? Yes / No
14. If yes, from which organization/source?
15. How does the information compare?
16. Would you prefer to receive information by e-mail? Yes / No
17. Would you prefer to receive your STARS newsletter electronically? Yes / No
18. Have you found the STARS website – www.stars-us.org to be of use Yes / No
19. Would you be interested in attending a Conference run by STARS? Yes / No
20. Would you be interested in becoming a STARS volunteer? Yes / No
21. Would you be prepared to fundraise on behalf of STARS? Yes / No
22. How did you hear about STARS? Medical Professional Internet Friend Media Other (please specify)
23. Other
24. Any further comments / suggestions for future booklets you would like to see published