SURVEY OF SENIORS (aged 50 and older) IN GERMANTOWN
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This questionnaire is designed for Germantown’s senior population aged 50 and older as a way to assess their knowledge and perceptions of current facilities, programs and services available to seniors within the Germantown community. The online survey response system provides total anonymity for those completing this questionnaire, and survey results will be released only in statistical summary form. Completion should take only about 10 minutes and your participation is very important in helping the City plan for the future. Please read carefully and check the correct response and fill in the appropriate blank space. NOTE: Some questions ask for multiple responses.
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1. I have lived in Germantown for approximately:

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2. My zip code is:

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3. Number of adults aged 50 and older in my household:

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4. Using a scale of one (1) to five (5), select a number to indicate how much you participate in each of the listed programs and services provided for seniors aged 50 and older, where 1 = “Very Little or No Participation” and 5 = “Highest Level of Participation.”

 1 = Very Little or No Participation2 = Some Participation3 = Moderate Participation4 = High Level of Participation5 = Highest Level of Participation
Care Giving
Senior Center
Social Activities
Employment Services
Educational Classes
Discussion/Support Groups
Transportation
Focused Volunteer Programs
Housing
Information & Assistance
Medical Care
Travel
Arts & Crafts Classes
Heath & Wellness
Computer Activities
Hobby Activities
Music Activities
Literary Activities
Outdoor Activities
Aquatic Activities
Services for seniors living outside Germantown (e.g. MIFA meals)
Other (not listed above)

5. During the next three to five years, which, if any, of these programs or services do you plan to use or think you might need that you are NOT currently using (check all that apply)?

6. What facilities, programs or events would you most like to see developed, offered or improved in Germantown for seniors aged 50 and older?

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7. Using a scale of one (1) to five (5), select a number to indicate the level of importance you would place on each of the following programs or services provided for seniors aged 50 and older, where 1 = “Not Important at All” and 5 = “Very Important.”

 1 = Not Important at All2 = Slightly Important3 = Moderately Important4 = Important5 = Very Important
Care Giving
Senior Center
Social Activities
Employment Services
Educational Classes
Discussion/Support Groups
Transportation
Focused Volunteer Programs
Housing
Information & Assistance
Medical Care
Travel
Arts & Crafts Classes
Heath & Wellness
Computer Activities
Hobby Activities
Music Activities
Literary Activities
Outdoor Activities
Aquatic Activities
Services for seniors living outside Germantown (e.g. MIFA meals)
Other (not listed above)
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8. On average, how often do you or members in your household participate in programs, activities or services offered by an organization or service provider within the city of Germantown?

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9. Using a scale of one (1) to five (5), select a number to indicate your level of participation in programs and services for seniors aged 50 and older within the following time intervals, where 1 = “Very Little or No Participation” and 5 = “Highest Level of Participation.”

 1 = Very Little or No Participation2 = Some Participation3 = Moderate Participation4 = High Level of Participation5 = Highest Level of Participation
7am to 11am
11am to 1pm
1pm to 5pm
5pm to 9pm
9pm to 12am
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10. Using a scale of one (1) to five (5), select a number to indicate your level of participation in programs and services for seniors aged 50 and older on the following days, where 1 = “Very Little or No Participation” and 5 = “Highest Level of Participation.”

 1 = Very Little or No Participation2 = Some Participation3 = Moderate Participation4 = High Level of Participation5 = Highest Level of Participation
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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11. Indicate the importance of the following factors in determining your participation in programs or services that are offered to seniors aged 50 and older using a scale of one (1) to five (5), where 1 = “Not Important at All” and 5 = “Very Important.”

 1 = Not Important at All2 = Slightly Important3 = Moderately Important4 = Important5 = Very Important
Seasonal or special events
Unique Program Offerings
Cost of Program
Quality of Facilities
Convenience
Time flexibility
Transportation
Trained staff
Accessibility to facilities/programs
Support from peers/family members
Varied range of activities
Other (not listed above)
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12. Which of the following best describes the membership fee or program service fee that you pay in order to participate in the majority of the programs or services offered for seniors aged 50 and older?

13. Do you have any interest in the use of facilities (building or space use) to provide programs or events for seniors aged 50 and older? (If so, please check all that apply)

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14. How do you get information about programs, services, or events for seniors aged 50 or older in Germantown (check all that apply)?

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15. My age group is:

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16. My gender is:

17. My race/ethnicity can be best described as:

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18. My current living arrangement can be best described as:

19. What best describes your household’s yearly gross income?

20. Are there additional comments you wish to share regarding programs and services provided for seniors aged 50 and older in Germantown?