Please complete our survey. Your answers will help determine what services are available and help us plan for the next four years. All information is confidential.

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* 1. Please check all that apply:

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* 2. What is your zip code?

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* 3. Gender

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* 4. Race (check all that apply)

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* 5. Marital Status

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* 6. In what year were you born?

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* 7. Highest Level of Education

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* 8. Annual household income

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* 9. How many people are supported by this annual income?

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* 10. As a senior, are you a caregiver?

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* 11. If yes, are you caring for (check all that apply):

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* 12. How important are the following?

  Important Not Important Does Not Apply
Knowing what senior services are available and how to get them.
Transportation to the grocery store, doctor’s office, pharmacy, senior centers or other errands.
Having a nutritious meal with my friends or other seniors.
Taking part in fun activities (such as crafts, music, games, trips, etc.) with other seniors.
Getting physical activity that is good for me.
Having someone to talk to when I feel lonely.
Information on how to eat healthy.
Having a meal delivered to my house because I am not able to cook.
Help keeping my home clean because I am not able to clean.
Help with repairs and maintenance of my home and yard because I am not able to complete it myself.
Help with bathing, dressing, grooming and toileting.
Help with washing and drying my laundry.
Help with taking my prescription medication.
Keeping warm or cool as the weather changes.
Learning how to prevent falls and other accidents.
Someone to protect my rights, safety, property or dignity.
Someone to call when I feel threatened or taken advantage of.
Modifications to my home so that I can get around safely.
A senior center that is close to my home.
Life-enriching volunteer opportunities in my community.

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* 13. Do you have a medical condition (physical, mental or emotional) that: (check all that apply)

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* 14. Are you aware of APPRISE services?

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* 15. Do you feel that your religious or cultural needs are being met? (specify)

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* 16. Where do you get your information about services and programs for seniors?

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