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FAIRFIELD CARES

1.Is Jefferson County IA your primary place of residence?
HOME HEALTHCARE SURVEY

Thanks to The Greater Jefferson County Foundation, City of Fairfield L.O.S.T. grant, and private donors for funding this survey.

Fairfield Cares is a non-profit dedicated to building a more responsive system of home health care that supports well-being and independence for senior citizens and those of all ages with needs for health, social, and other services in Jefferson County.

The purpose of this survey is to identify the needs and gaps in services and resources for Jefferson County residents who require assistance of any kind in order to remain safely in their homes for as long as possible. This data will be used to improve services and resources wherever possible.

Thank you for taking the time to fill out this survey.

YOU SHOULD COMPLETE THIS SURVEY ONLY IF BOTH OF THE FOLLOWING ARE TRUE:

1. You are a resident of Jefferson County

AND

2. You need or you have needed within the past five (5) years someone to provide ANY of the following services in your home because you have either a temporary or a permanent condition limiting your ability to take full care of yourself.
  • Care from an RN or a CNA
  • Physical or occupational therapy
  • Managing medications or housekeeping
  • Meal preparation, delivery
  • Bathing or toileting
  • Managing money & bills
  • Minor appliance repairs
  • Repairs or upgrades to make your home safe
  • Installation of safety devices
  • House or yard maintenance
  • Grocery shopping or errands
  • Childcare
  • Transportation to appointments
  • Companionship
  • Help accessing physical, social, and mental health resources.
CONFIDENTIALITY:
Your identity will not be asked for when you take this survey. All your answers will be automatically anonymous.

IF YOU NEED HELP TO COMPLETE THIS SURVEY
Send your name, phone number, and your question to:
surveyhelp@lisco.com

We’ll get back to you as soon as we can.

IF YOU COMPLETED A PAPER COPY OF THIS SURVEY
Please put your survey in the box at one of these locations:
  • Fairfield Public Library, 104 W. Adams St. – On rear of counter
  • Fairfield City Hall 118 S. Main St. – Inside first door
  • Universal Therapy, 1401 S. Main St. – On table of front desk
  • Revelations (Revs) Health Center, 114 N. Main St.
2.What is your age?(Required.)
3.What type of insurance coverage do you have? Check all that apply.(Required.)
4.What is your approximate average household income?(Required.)
5.Which of the following health conditions do you have? Mark all that apply.(Required.)
6.How many times have you fallen in the past 12 months?(Required.)
7.Have you been hospitalized or in a rehab facility within the past year?
8.If yes, did someone in the hospital or rehab facility work with you, a family member, and/or another representative to plan your discharge so you could receive the services/resources you needed?
9.If you received some, but not all of the services you needed, please mark the services you received:
10.Please check the services you needed but did not receive:
11.Are you homebound?
12.How many people currently live in your household?
13.If you live with someone, are they able and willing to assist you with any care needs?(Required.)
14.Are you disabled?
15.Does anyone else in your household require assistance with any medical needs or activities of daily living?(Required.)
16.Do you have a pet?
17.Do you currently wear a medical alert device?(Required.)
18.If yes, do you need help to care for a pet or pets - for example: feed them, take for a walk, clean litter box, take to vet, etc.?
19.Do you currently need assistance with any of the following activities? Check all that apply.
20.At any time in the past 5 years, have you been in need of assistance with any of the following activities? Check all that apply.
21.Do you currently use any meal delivery service? Such as Mom's Meals, Meals on Wheels, Meal Train, or other meal delivery services.
22.Do you require assistance with transfers such as getting into/out of bed, chairs, AND/OR your home?
23.Do you need assistance with toileting and toilet hygiene?(Required.)
24.Do you need assistance with dressing/undressing? (Required.)
25.Do you need any assistance with bathing, whether in the shower/bathtub or sponge bath?
26.Do you need any assistance with managing your medications, setting them up weekly, filling prescriptions, AND/OR remembering to take them at the correct times?(Required.)
27.On a scale of 0-10, how well do you understand your medications? What they are for, when to take them, side effects, etc.
0 - Not at all
10 - Extremely well
28.Do you require the use of an assistive device? Check all that apply. If you already have the device, please note.(Required.)
I NEED:
I ALREADY HAVE:
N/A - DO NOT NEED 
Cane
Walker
Wheelchair
Electric scooter
Hospital bed
Lift chair
Bed rail
Raised toilet seat/seat riser
Bedside commode
Grab bars
29.If you need any assistive devices, do you know where to obtain them?
30.If an assistive device is not available to borrow, do you need help to pay for it?
31.Are there stairs to enter your home?(Required.)
32.Are there multiple levels inside your home?(Required.)
33.Do you own or rent your place of residence?
34.If you rent, is your house or apartment in good, safe condition?
35.Do you need help to get your landlord to make the necessary repairs?
36.If you own your own home, is it in need of repairs or modifications to make it safe and livable?
37.If repairs/modifications are needed, please check all that is needed and whether or not you can afford to make repairs/modifications:(Required.)
CANNOT AFFORD:
CAN AFFORD:
N/A - NOT NEEDED:
Air conditioning 
Convert tub to walk-in shower
Doors
Furnace
Insulation 
Locks
Paint exterior/interior
Plumbing
Railings on stairs - interior/exterior
Ramp
Roof 
Safety bars
Screens
Siding
Windows
38.If repairs or modifications are needed and you cannot afford to pay for them, do you know where to apply for help to pay for the cost?
39.Do you need financial assistance for any of the following? Check all that apply.
40.Do you need help to apply for Social Security or SSI?
41.Do you need help to apply for a grant or loan for home repairs?
42.During the past year, how supported did you feel when you wanted or needed help from others? For example, if you felt lonely and wanted to talk to someone or got sick.(Required.)
43.During the past year, how disruptive were your physical health or emotional problems to your normal social activities with family, friends, neighbors, or groups?(Required.)
44.On a scale of 0-10, how well do you feel you understand your healthcare needs?
0 - Not at all
10 - Extremely well
45.Would you utilize a Senior Center, Adult Day Care, or similar services if they were available?
46.Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 12 months?
47.Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 5 years?
48.How many times have you needed assistance related to a healthcare need in the past 5 years?
49.If you have required in-home assistance in the past 5 years related to a healthcare need, who paid for those services? Check all that apply.
50.Did someone help you complete this survey?(Required.)