Please return to 2 Bank Street Batavia, NY 14020 by December 1, 2012 *CHECK ALL THAT APPLY*
GeneseeCounty Office for the Aging
2012Housing Survey
Call 585-343-1611 if questions- Return to the Office for the Aging by December 1, 2012
PLEASE CIRCLE OR PLACE CHECKMARK NEXT TO ALL THAT APPLY
Page 1 of 6 PLEASE RETURN THIS SURVEY BY DECEMBER 1, 2012 2012 Housing Survey Questions - OFA
Please return to 2 Bank Street Batavia, NY 14020 by December 1, 2012 *CHECK ALL THAT APPLY*
Gender
Male Female
Age
40-44 45-49
50-54 55-59
60-64 65-69
70-74 5+ 75-79
80-84 85-89
90-94 95+
Veteran
Yes No
Are you the Primary Caregiver of someone who is in need of assistance?
Yes No
Marital Status
Never Married Widowed
Married Separated
Divorced
Describe Yourself
Active
Some Restriction/Activity Level
Homebound
Disabled
Living Arrangements
Living Alone
Living with Spouse
Living with Friends or Others
Living with Other Relative/s
Page 1 of 6 PLEASE RETURN THIS SURVEY BY DECEMBER 1, 2012 2012 Housing Survey Questions - OFA
Please return to 2 Bank Street Batavia, NY 14020 by December 1, 2012 *CHECK ALL THAT APPLY*
Household Size
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10Annual Gross Household Income (before withholdings or deductions)
Less than$10,000 / $10,000
to
14,999 / $15,000 to $24,999 / $25,000 to $34,999 / $35,000 to $49,999 / $50,000 to $74,999 / $75,000 to $99,999 / $100,000 to $124,999 / $125,000 to $149,999 / $150,000 to $174,999 / $175,000 and
over
Page 1 of 6 PLEASE RETURN THIS SURVEY BY DECEMBER 1, 2012 2012 Housing Survey Questions - OFA
Please return to 2 Bank Street Batavia, NY 14020 by December 1, 2012 *CHECK ALL THAT APPLY*
Ethnicity
White Non-Hispanic Hispanic
American Indian/Alaskan African American
Asian/Pacific Islander
Do you rely on friends/family to help you keep up your home or with other needs?
Yes No
Do you hire paid services to help you with your needs?
Yes No
What needs do you currently have where you live?
Write in A, B, C, D as it applies to you
A = Not a need for me
B = A need for me, but no one to help me with it
C = A need for me, but Friends or Family help me with it
D = A need for me, but I pay someone to help me with it
___Bathing/Dressing ___ Cleaning/Laundry
___Shopping ___ Transportation
___Paying Bills/Banking ___ Medication Assistance
___Home Maintenance ___ Lawn/Yard Care
___Minor Home Repairs ___ Smoke Detectors
___Carbon Monoxide Detectors
___Home Modifications/Disabled Access
___Assistance/Heating Costs
___Furnace Repair/Replacement
___Hot Water Tank Repair/Replacement
___Insulation/Caulking
Current Living Arrangements
Own my home
Own a home that has urgent repair needs/violations
Live in a home where I have “Life Use”
Rent a house
Own Mobile Home on PrivateLand
Own Mobile Home & Pay Lot Rent in a Mobile
Home Community
Rent Apartment in Private Home
Rent Apartment in an Apartment Complex
Nursing Home/Adult Care Facility
Other______
Years Living at Present Address
Under 10 11 - 20
21 - 30 31 - 40 Over 41
If you own:
What is your home’s assessed value?
$______
Do you still have a mortgage/home equity loan?
Yes No
How much is still owed on your mortgage/loan?
$______Does not apply
How many years are left on your mortgage/loan?
______Does not apply
Do you have a “Reverse Mortgage”?
Yes No
What is your biggest monthly expense?
Please Specify______
Do You Receive GovernmentRent Subsidy?
Yes No
Are looking at other housing options?
Yes No
If you had your choice, which setting would you prefer?
City Village
Rural
Are you considering relocating within the county?
Yes No
Are you considering moving away from the county?
Yes
No
If Yes, Why? (Be sure to include all that apply)
To a warmer climate
To be near family members
To find supportive housing (meals, personal care, etc.)
Other______
If No, Why? (Be sure to include all that apply)
I want to stay near family members
My needs are met in this county
I like the community I live in now
Other______
Do you know what senior living is available in your community?
Yes No
Do you intend to move from your home in the next 5 years?
Yes No
If No, why not? (Check all that apply)
I like the house where I live
I like the community where I live
I like my privacy
I can’t afford rent or a new mortgage in my budget
It is too overwhelming to think of downsizing, packing, moving
Housingthat’s for sale needs too much work to update
My family will take care of me and my home
My house is paid for and I’m staying put
Nursing home placement is probable
Other______
Does your home currently have or would you like:
Have Would like
□ □ A step free entrance into the home?
□ □ Kitchen, Bedroom, & Full bath on 1st floor
□ □ Doors & Halls wide enough for wheelchair
□ □ Doorknobs & faucets with lever handles
□ □ Walk-in/roll in shower rather than a tub
□ □ Sidewalks to get to day to day services
If you are considering moving to alternate housing, what might it be?
Subsidized (government rent help) senior housing
Private rental housing
Non-subsidized senior rental housing
Senior rental apartment complex with supportive services (Such as meals, personal care, etc.)
Senior modular home complex
Cottage on property of family member’s land
Cottages in a senior community
Smaller house to purchase
Accessible home with 1st floor bath, laundry, bed
Which of the following problems might prompt you to consider moving to another living situation?
Yard/snow is too much Loneliness
Maintenance & repairs Need personal care
Lack of transportation House too much work
My home is not accessible (doorways, steps, bath, etc)
No family nearby to rely upon
Distance from stores, doctors, family etc.
Lack of social/entertainment opportunities
Financial opportunities or financial difficulties
Need assistance/housework
Need assistance/meal preparation
Need assistance/shopping
Need assistance/running errands
Don’t feel safe in my community
Other______
If you might consider buying a new home, what price range would you be willing to pay and able to afford?
Up to:
$ 40,000 - 59,999 $ 60,000 - 79,999
$ 80,000 - 99,999 $100,000 - 119,999
$120,000 - 139,999 $140,000 - 159,999
$160,000 -179,999 $180,000 - 199,999
$200,000 - 224,999 $225,000 - 249,999
$250,000+
If you are currently renting or considering renting,
what price range would you be willing to pay and able to affordmonthly? (NOT including utilities or added services like meals, housekeeping, lawn, snow removal)
Up to:
$ 400 - 499 $ 500 - 599
$ 600 - 699 $ 700 - 799
$ 800 - 899 $ 900 - 999
$ 1,000 - 1,099 $ 1,100 - 1,199
$ 1,200 - 1,299 $22 $ 1,300 - 1,399
$ 1,400 - 1,499 $1,500 - 1,599
If you were interested insenior housing, which of the following would best meet your current needs?
Studio 1 Bedroom
2 Bedroom 3 Bedroom
Not Interested in senior apartment living
If you were interested in senior housing, which of the following features interest you?
Common space for gathering/recreation
Group activities that involve social trips
Educational/Cultural opportunities and activities
Dining area that serves: (Circle all that apply) Breakfast Lunch Dinner
If needed in future, onsite shared aide services to assist with:
- Transfer in and out of bed, chair, or toilet
- Personal care
- Bathing
- Hair care
- Toileting
- Ostomy or catheter care
- Medication reminders
- Feeding
- Walking or wheeling
- Housekeeping/laundry
- Transportation
- Grocery shopping
- Errands
- Assistance/paying bills
- Other______
Housing that as my needs progress, the services progress, including assisted living and nursing home
Housing that as my needs progress, the services progress, but does NOT include assisted living and nursing home
Not interested in senior housing
I wouldseriously consider senior housing where:
my out of town family (including grandchildren) can stay near me under the same roof at no cost or at least a lower cost than a hotel
my family (including grandchildren) can gather in a home-like setting to cook and dine for big meals with a real dining room, not commercial looking
I can visit with friends and family in a room that is homelike, not a commercial looking community room
I can store things I don’t want to give up
I can tinker on cars or do woodworking
I can putter in a yard/garden
I can remain in my community where I am familiar with the people and services
I could walk to everyday goods and services
Sidewalks and/or walking/biking trails were close by
Public transportation is available
Other______
Would not even consider senior housing
If this type of housing is available in your area, when would you consider moving?
As soon as possible 2 - 3 years
3 - 5 years 5 or more years
Not interested at this time Unknown
Comments:______
______
______
Page 1 of 6 PLEASE RETURN THIS SURVEY BY DECEMBER 1, 2012 2012 Housing Survey Questions - OFA
Please return to 2 Bank Street Batavia, NY 14020 by December 1, 2012 *CHECK ALL THAT APPLY*
Page 1 of 6 PLEASE RETURN THIS SURVEY BY DECEMBER 1, 2012 2012 Housing Survey Questions - OFA