Helping Seniors Advocacy Survey

Question Title

* 1. ARE YOU RECEIVING LOCAL ELDER SERVICES NOW?

YES

NO - But I have in the past.

NO - I would like to but don't know/not sure who to call.

NO - I have no need for Elder Services

DON'T KNOW

YES

NO - But I have in the past.

NO - I would like to but don't know/not sure who to call.

NO - I have no need for Elder Services

DON'T KNOW

Optional: (Comments/Additional Thoughts)

Question Title

* 2. DO YOU EXPERIENCE LONG WAITING TIMES (15+ MINUTES) WHEN CALLING ELDER SERVICES AGENCIES?

YES - Quite frequently/Almost every time when I call.

SOMETIMES

NO - I have not experienced long waiting times when calling.

N/A - i have not called an Elder Service Agency

YES - Quite frequently/Almost every time when I call.

SOMETIMES

NO - I have not experienced long waiting times when calling.

N/A - i have not called an Elder Service Agency

Optional: (Comments/Specific Situations)

Question Title

* 3. HOW IMPORTANT IS FINDING THE CORRECT INFORMATION FOR YOUR NEEDS?

VERY IMPORTANT

SOMEWHAT IMPORTANT

NOT IMPORTANT

I DON’T KNOW

VERY IMPORTANT

SOMEWHAT IMPORTANT

NOT IMPORTANT

I DON’T KNOW

Optional: (Comments/Additional Thoughts)

Question Title

* 4. DO YOU KNOW HOW TO FIND THE INFORMATION FOR YOUR NEEDS?

YES

NOT APPLICABLE IN MY CASE

Optional: (Comments/Additional Thoughts)

Question Title

* 5. PLEASE RATE THE IMPORTANCE OF YOUR SENIOR NEEDS.
(Please rate each on a scale of 1 to 5 with 1 being NOT IMPORTANT & 10 being VERY IMPORTANT.)

	1 (Not Important)	2	3 (Somewhat Important)	4	5 (Very Important)	N/A (Not Applicable)
CAREGIVING/NEEDING HELP CAREGIVING	CAREGIVING/NEEDING HELP CAREGIVING 1 (Not Important)	CAREGIVING/NEEDING HELP CAREGIVING 2	CAREGIVING/NEEDING HELP CAREGIVING 3 (Somewhat Important)	CAREGIVING/NEEDING HELP CAREGIVING 4	CAREGIVING/NEEDING HELP CAREGIVING 5 (Very Important)	CAREGIVING/NEEDING HELP CAREGIVING N/A (Not Applicable)
FINANCES/HELP WITH ORGANIZING FINANCES	FINANCES/HELP WITH ORGANIZING FINANCES 1 (Not Important)	FINANCES/HELP WITH ORGANIZING FINANCES 2	FINANCES/HELP WITH ORGANIZING FINANCES 3 (Somewhat Important)	FINANCES/HELP WITH ORGANIZING FINANCES 4	FINANCES/HELP WITH ORGANIZING FINANCES 5 (Very Important)	FINANCES/HELP WITH ORGANIZING FINANCES N/A (Not Applicable)
HEALTH/GENERAL INFORMATION REGARDING HEALTH	HEALTH/GENERAL INFORMATION REGARDING HEALTH 1 (Not Important)	HEALTH/GENERAL INFORMATION REGARDING HEALTH 2	HEALTH/GENERAL INFORMATION REGARDING HEALTH 3 (Somewhat Important)	HEALTH/GENERAL INFORMATION REGARDING HEALTH 4	HEALTH/GENERAL INFORMATION REGARDING HEALTH 5 (Very Important)	HEALTH/GENERAL INFORMATION REGARDING HEALTH N/A (Not Applicable)
HOUSING & RELATED	HOUSING & RELATED 1 (Not Important)	HOUSING & RELATED 2	HOUSING & RELATED 3 (Somewhat Important)	HOUSING & RELATED 4	HOUSING & RELATED 5 (Very Important)	HOUSING & RELATED N/A (Not Applicable)
INFORMATION ON AGING & AGING PROGRAMS	INFORMATION ON AGING & AGING PROGRAMS 1 (Not Important)	INFORMATION ON AGING & AGING PROGRAMS 2	INFORMATION ON AGING & AGING PROGRAMS 3 (Somewhat Important)	INFORMATION ON AGING & AGING PROGRAMS 4	INFORMATION ON AGING & AGING PROGRAMS 5 (Very Important)	INFORMATION ON AGING & AGING PROGRAMS N/A (Not Applicable)
ISOLATION/BEING ALONE	ISOLATION/BEING ALONE 1 (Not Important)	ISOLATION/BEING ALONE 2	ISOLATION/BEING ALONE 3 (Somewhat Important)	ISOLATION/BEING ALONE 4	ISOLATION/BEING ALONE 5 (Very Important)	ISOLATION/BEING ALONE N/A (Not Applicable)
MEDICAL CARE & SERVICES	MEDICAL CARE & SERVICES 1 (Not Important)	MEDICAL CARE & SERVICES 2	MEDICAL CARE & SERVICES 3 (Somewhat Important)	MEDICAL CARE & SERVICES 4	MEDICAL CARE & SERVICES 5 (Very Important)	MEDICAL CARE & SERVICES N/A (Not Applicable)
SOCIAL ACTIVITES	SOCIAL ACTIVITES 1 (Not Important)	SOCIAL ACTIVITES 2	SOCIAL ACTIVITES 3 (Somewhat Important)	SOCIAL ACTIVITES 4	SOCIAL ACTIVITES 5 (Very Important)	SOCIAL ACTIVITES N/A (Not Applicable)
TRANSPORTATION	TRANSPORTATION 1 (Not Important)	TRANSPORTATION 2	TRANSPORTATION 3 (Somewhat Important)	TRANSPORTATION 4	TRANSPORTATION 5 (Very Important)	TRANSPORTATION N/A (Not Applicable)
PLANNING FOR AGING	PLANNING FOR AGING 1 (Not Important)	PLANNING FOR AGING 2	PLANNING FOR AGING 3 (Somewhat Important)	PLANNING FOR AGING 4	PLANNING FOR AGING 5 (Very Important)	PLANNING FOR AGING N/A (Not Applicable)

Question Title

* 6. HOW WELL DO OUR LOCAL GOVERNMENT AGENCIES HELP YOU WITH SENIOR NEEDS?
(Please rate each one on a scale of 1 to 5 with 1 being POOR and 10 being EXCELLENT)

	1 (Poor)	2	3 (Okay)	4	5 (Excellent)	N/A (Not Applicable)
CAREGIVING/NEEDING HELP CAREGIVING	CAREGIVING/NEEDING HELP CAREGIVING 1 (Poor)	CAREGIVING/NEEDING HELP CAREGIVING 2	CAREGIVING/NEEDING HELP CAREGIVING 3 (Okay)	CAREGIVING/NEEDING HELP CAREGIVING 4	CAREGIVING/NEEDING HELP CAREGIVING 5 (Excellent)	CAREGIVING/NEEDING HELP CAREGIVING N/A (Not Applicable)
FINANCES/HELP WITH ORGANIZING FINANCES	FINANCES/HELP WITH ORGANIZING FINANCES 1 (Poor)	FINANCES/HELP WITH ORGANIZING FINANCES 2	FINANCES/HELP WITH ORGANIZING FINANCES 3 (Okay)	FINANCES/HELP WITH ORGANIZING FINANCES 4	FINANCES/HELP WITH ORGANIZING FINANCES 5 (Excellent)	FINANCES/HELP WITH ORGANIZING FINANCES N/A (Not Applicable)
HEALTH/GENERAL INFORMATION REGARDING HEALTH	HEALTH/GENERAL INFORMATION REGARDING HEALTH 1 (Poor)	HEALTH/GENERAL INFORMATION REGARDING HEALTH 2	HEALTH/GENERAL INFORMATION REGARDING HEALTH 3 (Okay)	HEALTH/GENERAL INFORMATION REGARDING HEALTH 4	HEALTH/GENERAL INFORMATION REGARDING HEALTH 5 (Excellent)	HEALTH/GENERAL INFORMATION REGARDING HEALTH N/A (Not Applicable)
HOUSING & RELATED	HOUSING & RELATED 1 (Poor)	HOUSING & RELATED 2	HOUSING & RELATED 3 (Okay)	HOUSING & RELATED 4	HOUSING & RELATED 5 (Excellent)	HOUSING & RELATED N/A (Not Applicable)
INFORMATION ON AGING & AGING PROGRAMS	INFORMATION ON AGING & AGING PROGRAMS 1 (Poor)	INFORMATION ON AGING & AGING PROGRAMS 2	INFORMATION ON AGING & AGING PROGRAMS 3 (Okay)	INFORMATION ON AGING & AGING PROGRAMS 4	INFORMATION ON AGING & AGING PROGRAMS 5 (Excellent)	INFORMATION ON AGING & AGING PROGRAMS N/A (Not Applicable)
ISOLATION/BEING ALONE	ISOLATION/BEING ALONE 1 (Poor)	ISOLATION/BEING ALONE 2	ISOLATION/BEING ALONE 3 (Okay)	ISOLATION/BEING ALONE 4	ISOLATION/BEING ALONE 5 (Excellent)	ISOLATION/BEING ALONE N/A (Not Applicable)
MEDICAL CARE & SERVICES	MEDICAL CARE & SERVICES 1 (Poor)	MEDICAL CARE & SERVICES 2	MEDICAL CARE & SERVICES 3 (Okay)	MEDICAL CARE & SERVICES 4	MEDICAL CARE & SERVICES 5 (Excellent)	MEDICAL CARE & SERVICES N/A (Not Applicable)
SOCIAL ACTIVITES	SOCIAL ACTIVITES 1 (Poor)	SOCIAL ACTIVITES 2	SOCIAL ACTIVITES 3 (Okay)	SOCIAL ACTIVITES 4	SOCIAL ACTIVITES 5 (Excellent)	SOCIAL ACTIVITES N/A (Not Applicable)
TRANSPORTATION	TRANSPORTATION 1 (Poor)	TRANSPORTATION 2	TRANSPORTATION 3 (Okay)	TRANSPORTATION 4	TRANSPORTATION 5 (Excellent)	TRANSPORTATION N/A (Not Applicable)
PLANNING FOR AGING	PLANNING FOR AGING 1 (Poor)	PLANNING FOR AGING 2	PLANNING FOR AGING 3 (Okay)	PLANNING FOR AGING 4	PLANNING FOR AGING 5 (Excellent)	PLANNING FOR AGING N/A (Not Applicable)

Question Title

* 7. DO YOU FIND THAT ELECTED OFFICIALS HERE IN BREVARD COUNTY (STATE, COUNTY, LOCAL) HAVE A GOOD UNDERSTANDING OF, AND FOCUS ON, THE NEEDS OF SENIORS IN OUR AREA?

Yes/Always - They are always focused on finding ways to address the needs of Seniors in our area.

Often - They often try to find ways to address the needs of Seniors in our area.

Occasionally - From time to time, they do address the needs of Seniors in our area, when convenient.

No/Never - They do not seem to address the needs of Seniors on an ongoing basis.

Have No Experience With/Do Not Know.

(Optional) Comments/Specifics Likes/Dislikes:

Question Title

* 8. IN YOUR OPINION, WHO IS MOST RESPONSIBLE FOR SENIORS SERVICES IN OUR AREA?

U.S. GOVERNMENT

STATE GOVERNMENT

COUNTY GOVERNMENT

CITY/TOWN GOVERNMENT

CHURCHES & CIVIC ORGANIZATIONS

FAMILY & FRIENDS

DON'T KNOW

Optional: (Comments/Thoughts)

Question Title

* 9.
HELPING SENIORS ASSISTS SENIORS VIA:

(1) OUR FREE SENIOR INFORMATION HELP LINE (321-473-7770);
(2) OUR HELPING SENIORS MEDIA OUTREACH (TELEVISION; RADIO; NEWSLETTER, ONLINE & SOCIAL MEDIA, AND COLUMNS, FROM OUR PRESIDENT/FOUNDER, JOE STECKLER, IN A WIDE VARIETY OF AREA PUBLICATIONS.)
(3) ADVOCATING, ON BEHALF OF SENIORS, COUNTY-WIDE.

WHAT COMMENTS/SUGGESTIONS DO YOU HAVE FOR HELPING SENIORS IN ORDER THAT WE MAY HELP YOU EVEN FURTHER?

Question Title

* 10. ENTER TO WIN (Optional):(Name can be anonymous)

Name

Address

Address 2

City / Town

State

ZIP

Phone

Question Title

* 1. ARE YOU RECEIVING LOCAL ELDER SERVICES NOW?

Question Title

* 2. DO YOU EXPERIENCE LONG WAITING TIMES (15+ MINUTES) WHEN CALLING ELDER SERVICES AGENCIES?

Question Title

* 3. HOW IMPORTANT IS FINDING THE CORRECT INFORMATION FOR YOUR NEEDS?

Question Title

* 4. DO YOU KNOW HOW TO FIND THE INFORMATION FOR YOUR NEEDS?

Question Title

* 5. PLEASE RATE THE IMPORTANCE OF YOUR SENIOR NEEDS.(Please rate each on a scale of 1 to 5 with 1 being NOT IMPORTANT & 10 being VERY IMPORTANT.)

Question Title

* 6. HOW WELL DO OUR LOCAL GOVERNMENT AGENCIES HELP YOU WITH SENIOR NEEDS?(Please rate each one on a scale of 1 to 5 with 1 being POOR and 10 being EXCELLENT)

Question Title

* 7. DO YOU FIND THAT ELECTED OFFICIALS HERE IN BREVARD COUNTY (STATE, COUNTY, LOCAL) HAVE A GOOD UNDERSTANDING OF, AND FOCUS ON, THE NEEDS OF SENIORS IN OUR AREA?

Question Title

* 8. IN YOUR OPINION, WHO IS MOST RESPONSIBLE FOR SENIORS SERVICES IN OUR AREA?

Question Title

Question Title

* 10. ENTER TO WIN (Optional):(Name can be anonymous)

* 5. PLEASE RATE THE IMPORTANCE OF YOUR SENIOR NEEDS.
(Please rate each on a scale of 1 to 5 with 1 being NOT IMPORTANT & 10 being VERY IMPORTANT.)

* 6. HOW WELL DO OUR LOCAL GOVERNMENT AGENCIES HELP YOU WITH SENIOR NEEDS?
(Please rate each one on a scale of 1 to 5 with 1 being POOR and 10 being EXCELLENT)