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* 1. What town do you live in?

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* 2. ZIP Code

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* 3. Here is a list of issues or activities that some people say are problems for older Americans. To what degree is each of these items a problem for you personally? (Please select one response to each item.)

  NO PROBLEM SOME PROBLEM SERIOUS PROBLEM
Elderly abuse, exploitation
Personal Safety (Crime)
Raising grandchildren
Language barriers (ability to access resources, services, and information)
Homelessness (including fear of becoming homeless)
Getting information about health insurance (AHCCCS, Medicare, Medigap, etc.)
Cost of energy/utilities
Providing care and supervision for an elderly family member
Transportation: Rural-Non Medical
Dementia, Alzheimer's, or similar conditions affecting you or someone close to you
Loss of spouse/loved one
Planning in advance for necessary health care
Isolation
Affordable assistive devices (hearing aids, glasses, canes, etc.)
Counseling or mental health services
Paying for prescription drugs
Bereavement/grief counseling/hospice services
Access to nutritious meals
Availability of health care providers (doctors, hospitals, etc.)
Maintenance and repair of home
The COVID pandemic affecting you or someone close to you
Personal Care (bathing, washing hair, etc.)
Feeling that you’re a valued member of your community (acceptance, inclusion, representation, tolerance, etc.)
Income (having enough money for basic needs)
Employment opportunities
Recreational or social opportunities
Cost of housing
Finding legal assistance
Accessibility modifications in my home (grab bars)
Homemaker services (shopping, housekeeping, meal preparation, etc.)
Maintaining my personal independence
Processing monthly bills and/or medical claims
Maintenance of yard
Getting information about health promotion (diet, disease prevention, etc.)
Loneliness
Getting information about services
Obtaining information on adult care (nursing home, assisted living facility, adult day care center, etc.)
Transportation
Obtaining information on volunteer opportunities
Ability to benefit from technology (internet, social media, tele-health, etc.)
Having someone check on me periodically
Telemarketing or In-Home Sales
Age discrimination (loans, insurance, employment, etc.)
Affordable dental care

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* 4. Whom do you usually go to for advice about your health insurance or Medicare? (Select all that apply):

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* 5. What is your source of transportation? (Select all that apply)

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* 6. Select the group that contains your age

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* 7. Gender

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* 8. What is your racial/ethnic origin?

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* 9. Primary language spoken?

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