* 1. What county do you live in?  (Select One)

* 2. Check all that apply.

* 3. For each service area, please rate how important each service is for older adults:  essential, important, somewhat important, or not important.

  Essential Important Somewhat Important Not Important No Opinion
Congregate Meals
Meals on Wheels
Adult Day Services (center to provide care during the day)
Information and Referral
Housing Options
Homemaking and Personal Care
Grab Bar Installation, Wheelchair Ramps, Bathroom Modification
Emergency Furnace, Plumbing, or Electrical Repair
Emergency Response Systems ("I've fallen and I can't get up.")
Transportation to Medical Appointments
Transportation to Other Settings
Classes to Learn about Managing Chronic Disease
Legal Assistance
Ombudsman Advocacy Services
Assistance with Applying for Benefits, Programs, etc.
Family Caregiver Respite and Education
Alzheimer's Family Support and Education
Counseling/Mental Health Services

* 4. Check the three senior services that are most in need of additional funding because of unmet needs in your community.  Select only three (3).

* 5. What do you think are the three concerns that have the greatest impact on a senior continuing to live independently?  Select only three (3).

* 6. Please enter any comments you have about senior needs, or other information that may be helpful for planning purposes.