2011 Survey of Adult & Aging Populations

1. I live in the following geographic region:

I live in the following geographic region:

2. I have lived in the community for how many years:

I have lived in the community for how many years:

3. Age:

Age: 64 and under

65 - 74

75 - 84

85 +

4. My gender is:

My gender is: Male

Female

Transgender

5. I am:

I am: Heterosexual

Homosexual

Bisexual

6. My Marital Status is:

My Marital Status is: Married

Gay Couple

Lesbian Couple

Widowed

Separated

Divorced

Never Married

Other

7. My primary language is

My primary language is

8. I am a:

I am a: Veteran

Family Member of a Veteran

9. Annual Income (If married)

Annual Income (If married) $0 - $14,709

$14,710 - $25,248

$25,249 - $46,860

$46,861 - 60,000

60,000 +

10. Annual Income (If single):

Annual Income (If single): $0 - $10,889

$10,890 - $16,908

$16,909 - $38,520

38,521 - 50,000

50,000 +

11. I am:

I am: Full-time employed

Part-time employed

Unemployed

Retired

12. I receive the following income:

I receive the following income: SSI/SSP

CAPI

Earned income

Retirement income

Veterans Benefits

13. My out of pocket medical expenses are:

My out of pocket medical expenses are: $0 - $250

$251 - $500

$500 +

14. Hispanic origin

Hispanic origin Yes

15. My race is:

My race is: American Indian or Alaskan Native

Asian Indian

Laotian

Black or African American

Cambodian

Chinese

Filipino

Guamanian or Chamorro

Japanese

Korean

Native Hawaiian

Samoan

Vietnamese

White

Other Asian

Other Pacific Islander

Other Race

Multiple Races

Declined to state

16. I live alone

I live alone Yes

17. I live with

I live with

18. I have a mortgage

I have a mortgage Yes

19. Housing: I live in a:

Housing: I live in a: House

Condominium/Town House

Apartment

Mobile Home/Trailer

Hotel/Boarding House

Board and Care/Assisted living Facility

Skill Nursing Facility

No residence

Shared

Other

20. Education: (please check highest grade level completed):

Education: (please check highest grade level completed): 0-8th Grade

9-12th Grade

Some College

College Graduate

Post Graduate

21. Public Transportation is accessible to me where I currently live:

Public Transportation is accessible to me where I currently live: Yes

22. My most often used form of transportation is:

My most often used form of transportation is: My own vehicle

Relatives

Friends

Senior Bus

Public Transportation

Taxi

Dial-a-ride/Para-Transit

Bicycle

None available

Other

23. Below is a list of issues/conditions/concerns which could affect your quality of life. Please check the box which best describes how much each one is a problem for you.

	No Problem	Minor Problem	Serious Problem
Crime	*Below is a list of issues/conditions/concerns which could affect your quality of life. Please check the box which best describes how much each one is a problem for you. Crime No Problem	Crime Minor Problem	Crime Serious Problem
Employment	Employment No Problem	Employment Minor Problem	Employment Serious Problem
Energy/utilities	Energy/utilities No Problem	Energy/utilities Minor Problem	Energy/utilities Serious Problem
Obtaining information and services/benefits	Obtaining information and services/benefits No Problem	Obtaining information and services/benefits Minor Problem	Obtaining information and services/benefits Serious Problem
Receiving Services/benefits	Receiving Services/benefits No Problem	Receiving Services/benefits Minor Problem	Receiving Services/benefits Serious Problem
Health Care	Health Care No Problem	Health Care Minor Problem	Health Care Serious Problem
Housing	Housing No Problem	Housing Minor Problem	Housing Serious Problem
Legal Affairs	Legal Affairs No Problem	Legal Affairs Minor Problem	Legal Affairs Serious Problem
Loneliness	Loneliness No Problem	Loneliness Minor Problem	Loneliness Serious Problem
Money to live on	Money to live on No Problem	Money to live on Minor Problem	Money to live on Serious Problem
Nutrition/Food	Nutrition/Food No Problem	Nutrition/Food Minor Problem	Nutrition/Food Serious Problem
Taking care of another person who under 18 years of age	Taking care of another person who under 18 years of age No Problem	Taking care of another person who under 18 years of age Minor Problem	Taking care of another person who under 18 years of age Serious Problem
Taking care of another adult	Taking care of another adult No Problem	Taking care of another adult Minor Problem	Taking care of another adult Serious Problem
Transportation	Transportation No Problem	Transportation Minor Problem	Transportation Serious Problem
Household Chores	Household Chores No Problem	Household Chores Minor Problem	Household Chores Serious Problem
Isolation	Isolation No Problem	Isolation Minor Problem	Isolation Serious Problem
Accidents in the home (e.g. falling)	Accidents in the home (e.g. falling) No Problem	Accidents in the home (e.g. falling) Minor Problem	Accidents in the home (e.g. falling) Serious Problem

24. Below is a list of activities that are difficult for some people. Please check the box that best describes how difficult each activity is for you.

	No Difficulty	Minor Difficulty	Serious Difficulty	Unable to Do
Eating	*Below is a list of activities that are difficult for some people. Please check the box that best describes how difficult each activity is for you. Eating No Difficulty	Eating Minor Difficulty	Eating Serious Difficulty	Eating Unable to Do
Bathing	Bathing No Difficulty	Bathing Minor Difficulty	Bathing Serious Difficulty	Bathing Unable to Do
Dressing/undressing	Dressing/undressing No Difficulty	Dressing/undressing Minor Difficulty	Dressing/undressing Serious Difficulty	Dressing/undressing Unable to Do
Walking	Walking No Difficulty	Walking Minor Difficulty	Walking Serious Difficulty	Walking Unable to Do
Getting in and out of bed	Getting in and out of bed No Difficulty	Getting in and out of bed Minor Difficulty	Getting in and out of bed Serious Difficulty	Getting in and out of bed Unable to Do
Getting to the bathroom	Getting to the bathroom No Difficulty	Getting to the bathroom Minor Difficulty	Getting to the bathroom Serious Difficulty	Getting to the bathroom Unable to Do
Preparing meals	Preparing meals No Difficulty	Preparing meals Minor Difficulty	Preparing meals Serious Difficulty	Preparing meals Unable to Do
Shopping for personal items	Shopping for personal items No Difficulty	Shopping for personal items Minor Difficulty	Shopping for personal items Serious Difficulty	Shopping for personal items Unable to Do
Medication management	Medication management No Difficulty	Medication management Minor Difficulty	Medication management Serious Difficulty	Medication management Unable to Do
Managing money	Managing money No Difficulty	Managing money Minor Difficulty	Managing money Serious Difficulty	Managing money Unable to Do
Using the telephone	Using the telephone No Difficulty	Using the telephone Minor Difficulty	Using the telephone Serious Difficulty	Using the telephone Unable to Do
Doing heavy housework	Doing heavy housework No Difficulty	Doing heavy housework Minor Difficulty	Doing heavy housework Serious Difficulty	Doing heavy housework Unable to Do
Doing light housework	Doing light housework No Difficulty	Doing light housework Minor Difficulty	Doing light housework Serious Difficulty	Doing light housework Unable to Do
Transportation ability	Transportation ability No Difficulty	Transportation ability Minor Difficulty	Transportation ability Serious Difficulty	Transportation ability Unable to Do

25. For each activity with which you have difficulty, please check who helps you with that activity. You may check multiple answers.

	Spouse	Other Relative	Friend	Agency Volunteer	Paid Worker	No One
Eating	*For each activity with which you have difficulty, please check who helps you with that activity. You may check multiple answers. Eating Spouse	Eating Other Relative	Eating Friend	Eating Agency Volunteer	Eating Paid Worker	Eating No One
Bathing	Bathing Spouse	Bathing Other Relative	Bathing Friend	Bathing Agency Volunteer	Bathing Paid Worker	Bathing No One
Dressing/undressing	Dressing/undressing Spouse	Dressing/undressing Other Relative	Dressing/undressing Friend	Dressing/undressing Agency Volunteer	Dressing/undressing Paid Worker	Dressing/undressing No One
Walking	Walking Spouse	Walking Other Relative	Walking Friend	Walking Agency Volunteer	Walking Paid Worker	Walking No One
Getting in and out of bed	Getting in and out of bed Spouse	Getting in and out of bed Other Relative	Getting in and out of bed Friend	Getting in and out of bed Agency Volunteer	Getting in and out of bed Paid Worker	Getting in and out of bed No One
Getting to the bathroom	Getting to the bathroom Spouse	Getting to the bathroom Other Relative	Getting to the bathroom Friend	Getting to the bathroom Agency Volunteer	Getting to the bathroom Paid Worker	Getting to the bathroom No One
Preparing meals	Preparing meals Spouse	Preparing meals Other Relative	Preparing meals Friend	Preparing meals Agency Volunteer	Preparing meals Paid Worker	Preparing meals No One
Shopping for personal items	Shopping for personal items Spouse	Shopping for personal items Other Relative	Shopping for personal items Friend	Shopping for personal items Agency Volunteer	Shopping for personal items Paid Worker	Shopping for personal items No One
Medication management	Medication management Spouse	Medication management Other Relative	Medication management Friend	Medication management Agency Volunteer	Medication management Paid Worker	Medication management No One
Managing money	Managing money Spouse	Managing money Other Relative	Managing money Friend	Managing money Agency Volunteer	Managing money Paid Worker	Managing money No One
Using the telephone	Using the telephone Spouse	Using the telephone Other Relative	Using the telephone Friend	Using the telephone Agency Volunteer	Using the telephone Paid Worker	Using the telephone No One
Doing heavy housework	Doing heavy housework Spouse	Doing heavy housework Other Relative	Doing heavy housework Friend	Doing heavy housework Agency Volunteer	Doing heavy housework Paid Worker	Doing heavy housework No One
Doing light housework	Doing light housework Spouse	Doing light housework Other Relative	Doing light housework Friend	Doing light housework Agency Volunteer	Doing light housework Paid Worker	Doing light housework No One
Transportation ability	Transportation ability Spouse	Transportation ability Other Relative	Transportation ability Friend	Transportation ability Agency Volunteer	Transportation ability Paid Worker	Transportation ability No One

Other (please specify)

26. The two problems from Question 25 that affect me the most are:

The two problems from Question 25 that affect me the most are: First problem:
Second problem:

27. Other problems or comments that I have are:

Other problems or comments that I have are:

28. If you need help with any problem, who would you turn to for help (check all that apply)?

If you need help with any problem, who would you turn to for help (check all that apply)? Spouse

Relative

Friend

Health Care Provider

Senior Center

Place of Worship

Neighbor

City or County Services

Other (please specify)

2011 Survey of Adult & Aging Populations
Exit this survey

1. Aging Survey

1. I live in the following geographic region:

2. I have lived in the community for how many years:

3. Age:

4. My gender is:

5. I am:

6. My Marital Status is:

7. My primary language is

8. I am a:

9. Annual Income (If married)

10. Annual Income (If single):

11. I am:

12. I receive the following income:

13. My out of pocket medical expenses are:

14. Hispanic origin

15. My race is:

16. I live alone

17. I live with

18. I have a mortgage

19. Housing: I live in a:

20. Education: (please check highest grade level completed):

21. Public Transportation is accessible to me where I currently live:

22. My most often used form of transportation is:

23. Below is a list of issues/conditions/concerns which could affect your quality of life. Please check the box which best describes how much each one is a problem for you.

24. Below is a list of activities that are difficult for some people. Please check the box that best describes how difficult each activity is for you.

25. For each activity with which you have difficulty, please check who helps you with that activity. You may check multiple answers.

26. The two problems from Question 25 that affect me the most are:

27. Other problems or comments that I have are:

28. If you need help with any problem, who would you turn to for help (check all that apply)?

2011 Survey of Adult & Aging PopulationsExit this survey

1. Aging Survey

1. I live in the following geographic region:

2. I have lived in the community for how many years:

3. Age:

4. My gender is:

5. I am:

6. My Marital Status is:

7. My primary language is

8. I am a:

9. Annual Income (If married)

10. Annual Income (If single):

11. I am:

12. I receive the following income:

13. My out of pocket medical expenses are:

14. Hispanic origin

15. My race is:

16. I live alone

17. I live with

18. I have a mortgage

19. Housing: I live in a:

20. Education: (please check highest grade level completed):

21. Public Transportation is accessible to me where I currently live:

22. My most often used form of transportation is:

23. Below is a list of issues/conditions/concerns which could affect your quality of life. Please check the box which best describes how much each one is a problem for you.

24. Below is a list of activities that are difficult for some people. Please check the box that best describes how difficult each activity is for you.

25. For each activity with which you have difficulty, please check who helps you with that activity. You may check multiple answers.

26. The two problems from Question 25 that affect me the most are:

27. Other problems or comments that I have are:

28. If you need help with any problem, who would you turn to for help (check all that apply)?

2011 Survey of Adult & Aging Populations
Exit this survey