AgingServices Survey

(enter community name)is partnering with (enter partner agency name)and other local partners to develop a Regional Aging Services Network. The Network will assist communities and individuals to offer more choices and independent lifestyles to people aged 65 years and more. Your thoughts are important to this goal. Please take a few moments to answer the following questions.

  1. How interested are you in each of the following opportunities? (Please check boxes.)

Your Interests / Very Interested / Somewhat Interested / Not Interested / Not Sure
Connecting with new people face-to-face.
Connecting with people or services online.
Volunteering and helping others.
One-call referral to needed services.
Pre-negotiated service discounts.
Assistance with services – e.g. errands, rides, home repairs.
  1. What are your plans for the future(Please circle the letter for your favored choice.)

a. Stay where I am, with support services.
b. Move in with family locally.
c. Move in with family out of this area. / d. Find someone to share housing.
e. Move to a retirement community.
f. Other (please specify):______
  1. What services or activities might help you to continue living in your home?(Please circle the letter of all that apply.)

  1. Rides to appointment
  2. Rent/mortgage assistance
  3. Utility assistance
  4. Job placement assistance
  5. Medical care or prescription assistance
  6. Daily calls to make sure I am okay
  7. Someone to visit me in my home
  8. Grocery shopping
  9. Someone go to medical appointments with me.
/
  1. Home/yard care
  2. Dental, hearing or vision care
  3. Physical fitness, exercise
  4. Assistance with pet care
  5. Food or meal assistance
  6. Other (please specify):______
  7. I do not/will need services to live at home.
  8. I do not want to continue living at home.

4.Are you able to access the services you need?

Yes ☐If No, please describe needed services: ______

5.If you are you are accessing services, who is helping you or who would you expect to help?(Please circle the letter for each source of assistance.)

  1. Family
  2. Friends
  3. Neighbors
  4. Place of worship
/
  1. Nonprofit agency
  2. Government
  3. For-profit company
  4. Other: ______

6.Would you be willing to pay an annual fee to receive assistance to access services?

  1. $10-50 a year
  2. $51-100 a year
  3. $101-250 a year
/
  1. $251-500 a year
  2. I am not willing or able to pay for assistance
  3. Other, please explain: ______

7.Would you be willing to volunteer in exchange for receiving assistance?

  1. Yes I would like to volunteer in the community.
  2. Yes, but only if I could volunteer in my home.
/
  1. I am unable to volunteer.
  2. I am interested in volunteering.

8.Whom do you consider to be a leader in your neighborhood (i.e. individuals, businesses, places of worship, nonprofit agencies)?

______

9.Would you like to be involved in learning more about a project to help people remain living in their homes?Yes ☐No ☐If yes, please provide contact information.

Name: ______Address: ______

Telephone:______Email:______

For more information on the project, please visit (enter website address). If you have any questions or suggestions, please contact (enter name, phone number and email address). Thank you for sharing your time and opinions with us.

To help us better understand your feedback, we would appreciate some brief information about you. (All answers are kept anonymous. Please circle the letter for your responses.)

1. Are you a:
a. Single male
b. Single female
c. Couple
2. Your birth year: 19____
3. How is your health?
  1. Excellent
  2. Very good
  3. Good
  4. Fair
  5. Poor
4. Your racial/ethnicity
  1. African American/Black
  2. Caucasian/White
  3. Hispanic/Latino
  4. Pacific Islander/Asian
  5. Other: ______
/ 5. What is your zip code:
______
6. How long have you lived in your neighborhood:
  1. Less than 5 years
  2. Five to 10 years
  3. More than 10 year
7. Do you use a computer for:
  1. E-mail
  2. Research/Surfing
  3. Shopping
  4. Banking
  5. Social networking
/ 8. Which of the following best describes your annual household income?
  1. Under $35,000
  2. $35,000-49,999
  3. $50,000-74,999
  4. $75,000-99,999
  5. $100,000-149,999
  6. $150,000 or more
9. Monthly household income:
a. I do not have enoughmoney to meet my needs
b. I do have enough money to meet my needs
c. I have more thanenough to money to meet my needs