North Central-Flint Hills Area Agency on Aging, Inc. Needs Assessment for Kansas Seniors (ages 60 and over)

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1. I am:

Female

Male

Nonbinary

Decline to state

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2. I am:

Single

Married

Widowed

Divorced

Separated

In a Committed relationship (not married)

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3. My age Is:

Under 60

60-64

65-69

70-74

75-79

80-84

85-89

90-94

95+

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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+

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5. Which ethnic background do you identify with?

African American

Asian/Pacific Islander

Hispanic

Native American

White/Non-Hispanic

Other (please specify)

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6. How many people live in your household including yourself?

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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

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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

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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)

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10. I have access to the Internet:

Yes

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11. If Yes,

Via Smart Phone

Via Computer/Tablet

Not Applicable

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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)

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13. I feel responsible for the well being and giving of care to another person?

YES

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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)

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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+

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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)

North Central-Flint Hills Area Agency on Aging, Inc. Needs Assessment for Kansas Seniors (ages 60 and over)

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* 1. I am:

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* 2. I am:

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* 3. My age Is:

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* 4. If married/committed relationship my spouse's/partner's age is:

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* 5. Which ethnic background do you identify with?

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* 6. How many people live in your household including yourself?

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* 7. My monthly household income is:

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* 8. I live:

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* 9. I live in the following KS County:

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* 10. I have access to the Internet:

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* 11. If Yes,

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* 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.

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* 13. I feel responsible for the well being and giving of care to another person?

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* 14. If you feel responsible for the well being and giving of care to another person, please tell us who you care for:

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* 15. What is the age of the person you are caring for?

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* 16. Does the person you feel responsible for the well being and giving care to have any of the following:

1. I am:

2. I am:

3. My age Is:

4. If married/committed relationship my spouse's/partner's age is:

5. Which ethnic background do you identify with?

6. How many people live in your household including yourself?

7. My monthly household income is:

8. I live:

9. I live in the following KS County:

10. I have access to the Internet:

11. If Yes,

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.

13. I feel responsible for the well being and giving of care to another person?

14. If you feel responsible for the well being and giving of care to another person, please tell us who you care for:

15. What is the age of the person you are caring for?

16. Does the person you feel responsible for the well being and giving care to have any of the following: