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Fairfield Cares is a local non-profit dedicated to building a more responsive, compassionate system of care that supports health and independence for senior citizens and those of all ages with special needs for health care and social support in our community. We are looking into creative solutions that will work for our community and its needs. We want to foster a
community environment where people thrive from cradle to grave.

The following questions will guide our focus on addressing the gaps in care needs facing our community's residents.

WHO SHOULD COMPLETE THE SURVEY:
Residents of Jefferson County, IA who currently or in the past 5 years have needed skilled or unskilled caregiving assistance.

CONFIDENTIALITY:
All responses to the survey are automatically anonymous and aggregated in a manner that prevents the identification of individual respondents.

For additional assistance with completing this survey contact Vanessa Pohren at
Phone: 641-451-9978
Email: vanessapohren.ffc@gmail.com
Website: www.fairfieldcares.net

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

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2. What is your age?

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3. What type of insurance coverage do you have? Check all that apply.

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4. What is your approximate average household income?

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5. Which of the following health conditions do you have? Mark all that apply.

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6. Are you homebound? 

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7. Are you disabled?

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8. Do you currently wear a medical alert device?

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9. How many times have you fallen in the past 12 months?

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10. Have you been hospitalized or in a rehab facility within the past year?

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11. 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?

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12. If you received some, but not all of the services you needed, please mark the services you received:

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13. Please check the services you needed but did not receive:

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14. How many people currently live in your household?

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15. If you live with someone, are they able and willing to assist you with any care needs?

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16. Does anyone else in your household require assistance with any medical needs or activities of daily living?

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17. Do you have a pet?

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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.?

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19. Do you currently need assistance with any of the following activities? Check all that apply

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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

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21. Do you currently use any meal delivery service? Such as Mom's Meals, Meals on Wheels, Meal Train, or other meal delivery services.

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22. Do you require assistance with transfers such as getting into/out of bed, chairs, AND/OR your home?

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23. Do you need assistance with toileting and toilet hygiene?

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24. Do you need assistance with dressing/undressing? Including but not limited to undergarments, shoes, and jacket/coat etc.

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25. Do you need any assistance with bathing, whether in the shower/bathtub or sponge bath?

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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?

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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
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i We adjusted the number you entered based on the slider’s scale.

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28. Do you require the use of an assistive device? Check all that apply. If you already have the device, please note.

  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

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29. If you need any assistive devices, do you know where to obtain them?

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30. If an assistive device is not available to borrow, do you need help to pay for it?

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31. Are there stairs to enter your home?

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32. Are there multiple levels inside your home?

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33. Do you own or rent your place of residence?

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34. If you rent, is your house or apartment in good, safe condition?

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35. Do you need help to get your landlord to make the necessary repairs?

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36. If you own your own home, is it in need of repairs or modifications to make it safe and livable?

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37. If repairs/modifications are needed, please check all that is needed and whether or not you can afford to make repairs/modifications:

  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

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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?

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39. Do you need financial assistance for any of the following? Check all that apply.

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40. Do you need help to apply for Social Security or SSI?

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41. Do you need help to apply for a grant or loan for home repairs?

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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.

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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?

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44. On a scale of 0-10, how well do you feel you understand your healthcare needs?

0 - Not at all 10 - Extremely well
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i We adjusted the number you entered based on the slider’s scale.

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45. Would you utilize a Senior Center, Adult Day Care, or similar services if they were available?

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46. Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 12 months?

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47. Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 5 years?

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48. How many times have you needed assistance related to a healthcare need in the past 5 years?

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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.

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50. Did someone help you complete this survey?

0 of 50 answered
 

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