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North Central-Flint Hills Area Agency on Aging, Inc. Needs Assessment for Kansas Seniors (ages 60 and over)
1.
I am:
Female
Male
Nonbinary
Decline to state
2.
I am:
Single
Married
Widowed
Divorced
Separated
In a Committed relationship (not married)
3.
My age Is:
Under 60
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95+
4.
If married/committed relationship my spouse's/partner's age is:
Under 60
60-64
65-69
70-74
75-79
80-84
85-89
90+
5.
Which ethnic background do you identify with?
African American
Asian/Pacific Islander
Hispanic
Native American
White/Non-Hispanic
Other (please specify)
6.
How many people live in your household including yourself?
1
2
3
4
5
6+
7.
My monthly household income is:
Less than $798
$799 - $1,064
$1,065 - $1,1330
$1,331 - $1,596
$1,597 - $2,128
$2,129 - $2,660
$2,661 - $3,192
$3,193 and up
I am not sure/ I don't know
8.
I live:
In a City (24,000+)
In a small city (6,000-24,000)
Small Town (6,000-1)
Outside of City limits
9.
I live in the following KS County:
Chase
Clay
Cloud
Dickinson
Ellsworth
Geary
Jewell
Lincoln
Lyon
Marion
Mitchell
Morris
Ottawa
Pottawatomie
Republic
Riley
Saline
Wabaunsee
Out of State
Other (please specify)
10.
I have access to the Internet:
Yes
No
11.
If Yes,
Via Smart Phone
Via Computer/Tablet
Not Applicable
12.
If you are someone who regularly receives care from someone else please tell us who you receive care from. Please mark all that apply.
Not Applicable
Spouse
Child
Other Relative
Area Agency on Aging
Home Health Agency
Church
Friend/Neighbor
Other (please specify)
13.
I feel responsible for the well being and giving of care to another person?
YES
NO
14.
If you feel responsible for the well being and giving of care to another person, please tell us who you care for:
Not Applicable
Spouse
Partner
Parent
Child
Other Relative
Friend/ Neighbor
Other (please specify)
15.
What is the age of the person you are caring for?
Not Applicable
Under 18
18-49
50-59
60-64
65-69
70-74
75-79
80-89
90+
16.
Does the person you feel responsible for the well being and giving care to have any of the following:
Not Applicable
Physical Disability
Traumatic Brain Injury
Mental Disability
Dementia/Alzheimer's
Other (please specify)
Current Progress,
0 of 30 answered
