Lake Cumberland Area Agency on Aging and Independent Living 

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* 2. What is your age?

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* 6. Please indicate your annual household income.

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* 7. What is your marital status?

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* 8. What level of school have you completed?

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* 9. Are you a U.S. Military Veteran or Spouse of a Military Veteran?

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* 10. Are you registered to vote?

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* 11. Do you have the following?  Check all that apply.

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* 12. What is your primary language?

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* 13. Do you identify as having a disability or impairment?  Check all that apply.

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* 14. What type of transportation do you typically use?

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* 15. Do you have any of the following chronic health issues?

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* 16. How often do you experience difficulties in paying for your medications?

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* 17. How much of your out of pocket medical costs are you able to pay?

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* 18. Do you utilize assistance to select a plan during Medicare Open Enrollment?

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* 19. Do you participate in community health screenings?

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* 20. How many times have you been hospitalized in the past 6 months?

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* 21. If you were being released from the hospital back to your home, which of the following services would be helpful to you?

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* 22. Are you a caregiver for someone in your household or someone living nearby?

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* 23. Who is the person you care for?

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* 24. How old is the person that you care for?

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* 25. Does the person you are caring for have a diagnosis of dementia or Alzheimer's?

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* 26. Do you use technology devices while caring for your loved one?  If so, which ones?

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* 27. Do you eat most meals alone?

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* 28. Do you have difficulty preparing and cooking meals?

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* 29. Do you ever eat meals at your local senior center?

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* 30. Do you have enough money to pay for food?

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* 31. Do you receive home delivered meals?

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* 32. Do you utilize a local food pantry to supplement your food supply?

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* 33. Do you have regular access to fresh fruits and vegetables?

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* 34. Have you ever used on-line grocery shopping/delivery?

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* 35. In the last 6 months, were you ever hungry but didn't eat because there wasn't enough money for food?

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* 36. In the last 6 months, did you ever cut the size of your meals or skip meals because there wasn't enough money for food?

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* 37. In-home assistance (meals, cleaning, bathing)

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* 38. Adult Day Care Services

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* 39. Assisted Living Services

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* 40. Retirement Community Services

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* 41. Subsidized Housing

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* 42. Nursing or Other Long-Term Care Facility

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* 43. Feeling unsafe at home or in your neighborhood...

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* 44. Avoiding accidents, falling or losing balance...

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* 45. Being a victim of crime...

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* 46. Having enough money for food, shelter or clothing...

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* 47. Being able to pay for heat and other utilities...

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* 48. Taking a bath (washing hair, shaving, etc.)...

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* 49. Cleaning your home...

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* 50. Shopping and preparing meals...

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* 51. Having a way to get to your doctor, pharmacy, etc.

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* 52. Using public transit/Uber or Lyft (bus, taxi, etc.)...

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* 53. Being able to drive your own car...

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* 54. Having/obtaining affordable housing...

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* 55. Finding help for home repairs...

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* 56. A place to go eat and socialize...

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* 57. Attending a religious gathering...

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* 58. Attending a Senior Center...

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* 59. Visiting with family, friends and neighbors...

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* 60. Attending counseling services or support groups...

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* 61. Feeling lonely and sad...

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* 62. Developing an emergency plan (natural disasters, pandemic, etc.)...

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* 63. Having family or others you can call on to help in an emergency...

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* 64. Having someone to talk to...

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* 65. Taking a break to meet your own needs...

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* 66. Dealing with agencies to get services...

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* 67. Getting information...

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* 68. Financial constraints...

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* 69. Caring for my grandchildren...

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* 70. Do you know how to access community resources for support?

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* 71. Do you know who to call to help an elderly/disabled person receive services?

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* 72. Have you ever called your local Aging and Disability Resource Center?

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* 73. Have you visited a Senior Center in the past 12 months?

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* 74. What media methods listed do you feel are most effective to make information available to people in the community?  Check all that apply.

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* 75. Are there any other needs within your community you are aware of that are not currently being met for older adults or individuals with disabilities?

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* 76. Did the effects of COVID-19 impact any of your answers?

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* 77. Being able to remain in your own home...

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