Activity Director’s Feedback Form

Please complete for each Creative Aging program/performance at your facility.

Download Feedback Form

Facility Name*:

Your Name*:

Your Email Address*:

Program Date & Time*:


Time artist arrived:

Time artist started performing:

Staff person(s) who attended the performance:

Approximate number of attendees (including staff and aides)*:

Approximate number of attendees 65+ years old*:

Please rate the overall program by placing an ‘x’ next to the appropriate number, using the following scale.
 1 2 3 4 5 6 7 8 9 10

Please place an ‘x’ next to the words that describe why you gave this rating to this program.

The Artist was:
 Professional Appropriately attired Prompt Energetic Flexible Unprepared Insensitive Humorous

The Performance was:
 Professional Appropriately attired Prompt Energetic Flexible Unprepared Insensitive Humorous

The Performance contained:
 Appropriate music for the audience Appropriate volume Appropriate music for occasion Inappropriate music, volume, language and/or jokes

Please place an ‘x’ if the artist interacted with the audience*.
 Before During After

Did the artist contact you prior to the date of the performance? Yes No

Did you contact the artist prior to the date of the performance? Yes No

Please give an example of how today’s performance inspired a program attendee to join in and participate.*

What is the one thing you will remember about the performance?*

Please leave this field empty.