SURVEY OF SERVICE PROVIDERS FOR SENIORS IN GERMANTOWN

This questionnaire is designed to establish a community inventory of facilities, programs and services available to seniors aged 50 and older within the Germantown community. Completion should only take about 10 minutes and your participation is very important. Please read carefully and check the correct responses and fill in blank spaces where appropriate. NOTE: Some questions ask for multiple responses.

1. Please provide your organization information.

Please provide your organization information. Name of your Institution or Organization:
Address:
Telephone:
Email Address:
Web address:

2. Your service provider category can best be described as:

Your service provider category can best be described as: Civic Government Medical Education	Non-Profit Faith-based For-profit
Other (please specify in space below)

3. Using a scale of one (1) to five (5), indicate the level of participation your organization has from seniors aged 50 and older in each of the listed programs and services, where 1 = “Very Little Participation” and 5 = “Highest Level of Participation.” If your organization does NOT offer that service or program, select 6 or “Not Offered."

	1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Care Giving	Using a scale of one (1) to five (5), indicate the level of participation your organization has from seniors aged 50 and older in each of the listed programs and services, where 1 = “Very Little Participation” and 5 = “Highest Level of Participation.” If your organization does NOT offer that service or program, select 6 or “Not Offered." Care Giving 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Senior Center	Senior Center 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Social Activities	Social Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Employment Services	Employment Services 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Educational Classes	Educational Classes 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Discussion/	Discussion/ 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Support Groups	Support Groups 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Transportation	Transportation 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Focused Volunteer Programs	Focused Volunteer Programs 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Housing	Housing 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Information & Assistance	Information & Assistance 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Medical Care	Medical Care 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Travel	Travel 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Arts & Crafts Classes	Arts & Crafts Classes 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Health & Wellness	Health & Wellness 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Computer Activities	Computer Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Hobby Activities	Hobby Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Music Activities	Music Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Literary Activities	Literary Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Outdoor Activities	Outdoor Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Aquatic Activities	Aquatic Activities 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Services for seniors living outside Germantown (e.g. MIFA meals)	Services for seniors living outside Germantown (e.g. MIFA meals) 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered
Other	Other 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Offered

If "other" programs or services are offered, list here

4. During the next three to five years, which, if any, of these programs or services does your organization plan to provide for seniors aged 50 and older that you are NOT currently providing?

During the next three to five years, which, if any, of these programs or services does your organization plan to provide for seniors aged 50 and older that you are NOT currently providing? Our organization does NOT plan to add any new programs or activities within the next 3-5 years (if selected, proceed to question 5).

Care giving

Senior Center

Social Activities

Employment Services

Educational Classes

Discussion/Support Groups

Transportation Community Resources

Focused Volunteer Programs

Housing

Information & Assistance

Medical Care

Travel

Arts & Craft Classes

Health & Wellness

Computer Activities

Hobby Activities

Music Activities

Literary Activities

Outdoor Activities

Aquatic Activities

Services for seniors living outside of Germantown (Ex: MIFA meals delivery)

Other (Please describe in the space below)

5. Using a scale of one (1) to five (5), indicate the level of importance your organization places on each of the following programs or services provided to seniors aged 50 and older, where 1 = “Not Important at All" and 5 = "Very Important." If your organization does NOT offer the service or program, select 6 or “Not Offered."

	1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Care Giving	Using a scale of one (1) to five (5), indicate the level of importance your organization places on each of the following programs or services provided to seniors aged 50 and older, where 1 = “Not Important at All" and 5 = "Very Important." If your organization does NOT offer the service or program, select 6 or “Not Offered." Care Giving 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Senior Center	Senior Center 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Social Activities	Social Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Employment Services	Employment Services 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Educational Classes	Educational Classes 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Discussion/	Discussion/ 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Support Groups	Support Groups 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Transportation	Transportation 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Focused Volunteer Programs	Focused Volunteer Programs 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Housing	Housing 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Information & Assistance	Information & Assistance 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Medical Care	Medical Care 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Travel	Travel 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Arts & Crafts Classes	Arts & Crafts Classes 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Health & Wellness	Health & Wellness 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Computer Activities	Computer Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Hobby Activities	Hobby Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Music Activities	Music Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Literary Activities	Literary Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Outdoor Activities	Outdoor Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Aquatic Activities	Aquatic Activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered
Services for seniors living outside Germantown (e.g. MIFA meals)	Services for seniors living outside Germantown (e.g. MIFA meals) 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important	6 - Not Offered

6. How many years has your organization offered programs or services for seniors aged 50 or above?

How many years has your organization offered programs or services for seniors aged 50 or above? less than 1

1 to 5

6 to 10

11 to 15

16 to 20

20 or more

7. Indicate the average number of seniors (aged 50 or above) that your organization serves on an annual basis.

Indicate the average number of seniors (aged 50 or above) that your organization serves on an annual basis. < 100

101 to 250

251 to 500

501 to 1000

over 1000

8. Using a scale of one (1) to five (5), indicate the level of active participation in your programs and services by each of the following age groups, where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." If there is no participation by a particular age group, select six (6) or "No Participation."

	1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
50 to 54	Using a scale of one (1) to five (5), indicate the level of active participation in your programs and services by each of the following age groups, where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." If there is no participation by a particular age group, select six (6) or "No Participation." 50 to 54 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
55 to 64	55 to 64 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
65 to 74	65 to 74 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
75 to 84	75 to 84 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
85 and older	85 and older 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation

9. Using a scale of one (1) to five (5), indicate the level of participation by seniors in your programs and services within the following time intervals where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." If there is no participation within a particular time interval, select six (6) or "No Participation."

	1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
7am to 11am	Using a scale of one (1) to five (5), indicate the level of participation by seniors in your programs and services within the following time intervals where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." If there is no participation within a particular time interval, select six (6) or "No Participation." 7am to 11am 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
11am to 1pm	11am to 1pm 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
1pm to 5pm	1pm to 5pm 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
5pm to 9pm	5pm to 9pm 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation
9pm to 12am	9pm to 12am 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - No Participation

10. Using a scale of one (1) to five (5), indicate the level of participation by seniors in your programs and services on the following days where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." Select six (6) or "Not Available This Day," if programs and services are not offered on a particular day.

	1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Monday	Using a scale of one (1) to five (5), indicate the level of participation by seniors in your programs and services on the following days where 1 = "Very Little Participation" and 5 = "Highest Level of Participation." Select six (6) or "Not Available This Day," if programs and services are not offered on a particular day. Monday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Tuesday	Tuesday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Wednesday	Wednesday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Thursday	Thursday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Friday	Friday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Saturday	Saturday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day
Sunday	Sunday 1 - Very Little Participation	2 - Some Participation	3 - Moderate Participation	4 - High Level of Participation	5 - Highest Level of Participation	6 - Not Available This Day

11. Indicate the importance of the following factors in determining the success of the programs or services being offered within your organization using a scale of one (1) to five (5), where 1 = “Not Important at All" and 5 = "Very Important."

	1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Seasonal programs offered	Indicate the importance of the following factors in determining the success of the programs or services being offered within your organization using a scale of one (1) to five (5), where 1 = “Not Important at All" and 5 = "Very Important." Seasonal programs offered 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Financial Resources	Financial Resources 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Facilities	Facilities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Time Flexibility	Time Flexibility 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Transportation	Transportation 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Trained staff	Trained staff 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Accessibility to facilities/ programs	Accessibility to facilities/ programs 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Support from peers/family members	Support from peers/family members 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Varied range of activities	Varied range of activities 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important
Other	Other 1 - Not Important at All	2 - Slightly Important	3 - Moderately Important	4 - Important	5 - Very Important

If "other" is selected, list the factor(s) here

12. Which of the following best describes the membership fee or program service fee charged by your organization?

Which of the following best describes the membership fee or program service fee charged by your organization? No fee to user – Free Service through City program

No fee to user – Free Service through County program

No fee to user – Free Service through State program

No fee to user – Free Service through Federal program

No fee to user – Free Service provided by our organization

Membership or Program Service fee averages $50 or less per year for the user

Membership or Program Service fee averages $100 or less per year for the user

Membership or Program Service fee is between $101 and $250 per year for the user

Membership or Program Service fee is between $251 and $500 per year for the user

Membership or Program Service fee is more than $500 per year for the user

Medicare or Insurance

Other (Please describe in the space below)

13. Does your organization provide facilities (building or space use only) for seniors aged 50 and older? (If so, please check all that apply)

Does your organization provide facilities (building or space use only) for seniors aged 50 and older? (If so, please check all that apply) Our organization does not provide facilities (if selected, proceed to question 14).

Program rooms

Gymnasium

Kitchen/Cafeteria

Social/TV area

Pool

Tennis Courts

Walking Track

Fitness Room

Game Room

Other (please describe in space below)

14. How does your organization provide public information to its target market/audience?

How does your organization provide public information to its target market/audience? Brochures

Website

Emails

Newspaper

Flyers

Radio

Public Service Announcements

Not applicable

Other (Please describe in the space below)

15. Additional Comments:

Additional Comments:

16. Would your organization like a copy of the results from the study?

Would your organization like a copy of the results from the study? Yes