We thank you for participating in the Purposeful Aging Survey. 
Your responses and comments are greatly appreciated.

* 1. What is the name of the City or Town in which your home is located?

* 2. How long have you lived in this City/Town?

* 3. What is your 5-digit ZIP code?

* 4. How would you rate your City/Town as a place for people to live as they age?

* 5. How important is it for you to remain in your City/Town as you age?

* 6. As you age, how likely is it that you will move to a different home in your City/Town?

* 7. As you age, how likely is it that you will move to a different City/Town?

* 8. If you were to consider moving, why would you do so?

 
a. Looking for a different home size that meets your needs
b. Maintaining your current home will be too expensive
c. Fearing for your personal safety or security concerns
d. Looking for a home that will help you live independently as you age
e. Wanting to move to an area that has better health care facilities
f. Wanting to be closer to family
g. Needing more access to public transportation
h. Wanting to live in a different climate
i. Looking for an area that has a lower cost of living

* 9. What best describes your living arrangement?

* 10. What type of home is your primary home?

* 11. How important is it for you to be able to live in your own home as you age?

* 12. Have the following types of modifications or improvements been made to your home to enable you to stay there?

 
a. Easier access into or within your home such as a ramp, chairlift or elevator, or wider doorways
b. Bathroom modifications such as grab bars, handrails, a higher toilet or non-slip tiles
c. Putting a bedroom, bathroom, or kitchen on the first floor
d. Improved lighting
e. Installing a medical emergency response system that notifies others in case of emergency

* 13. Does the City/Town where you live have the following?

 
a. Home repair contractors who are trustworthy, do quality work, and are affordable
b. A home repair service for low-income and older adults
c. Seasonal services such as lawn work or snow removal for low-income and older adults
d. Affordable housing options for adults of varying income levels, such as older active adult communities, assisted living and communities with shared facilities and outdoor spaces
e. Well-maintained and safe parks that are within walking distance of your home
f. Public parks with enough benches
g. Sidewalks that are safe for pedestrians or wheelchairs
h. Well-maintained public buildings and facilities that are accessible to people of different physical abilities
i. Neighborhood watch program

* 14. How do you get around for things like shopping, visiting the doctor, running errands, or going to other places?

* 15. To your knowledge, does your City/Town have the following?

  Answer
a. Accessible and convenient public transportation
b. Affordable public transportation
c. Well-maintained public transportation vehicles
d. Reliable public transportation
e. Safe public transportation stops or areas
f. Special transportation services for people with disabilities and older adults
g. Well-maintained streets
h. Easy to read traffic signs
i. Enforced speed limits
j. Public parking lots, spaces and other areas to park
k. Affordable public parking
l. Well-lit, safe streets and intersections for all users (pedestrians, bicyclists, drivers)
m. Safe pedestrian crossings
n. Driver education/refresher courses

* 16. When compared to most people your age, how would you rate your health?

* 17. How often do you engage in some form of physical exercise (such as walking, running, biking, swimming, sports, strength training, yoga, stretching)?

* 18. Does the City/Town where you live have any of the following?

 
a. Health and wellness programs and classes in areas such as nutrition, smoking cessation, and weight control
b. Fitness activities specifically geared to older adults
c. Conveniently located health and social services
d. A service that helps older adults find and access health and supportive services
e. Conveniently located emergency care centers
f. Easy-to-find information on local health and supportive services
g. Home care services, including health, personal care and housekeeping
h. Well-trained certified home health care providers
i. Affordable home health care providers
j. Well-maintained hospitals and health care facilities
k. A variety of health care professionals, including specialists
l. Health care professionals who speak different languages
m. Easily understandable and helpful local hospital or clinic answering services
n. Respectful and helpful hospital clinical staff

* 19. About how frequently do you have contact with your friends, family, or neighbors? This interaction could be by phone, in person, e-mail, or social media (such as Facebook).

* 20. Is the contact described above…

* 21. Do you participate in continuing education or self-improvement classes/workshops? (CHECK ALL THAT APPLY)

* 22. Does the City/Town where you live have the following?

 
a. Conveniently located entertainment
b. Activities specifically geared to older adults
c. Activities that offer older adults discounts
d. Activities that are affordable to all residents
e. Activities that involve both younger and older adults
f. Accurate and widely publicized information about social activities
g. A variety of cultural activities for diverse populations
h. Local schools that involve older adults in events and activities
i. Continuing education classes
j. Social clubs, such as for books, gardening, crafts or hobbies
k. A range of volunteer activities to choose from
l. Volunteer training opportunities to help people perform better in their volunteer roles
m. Opportunities for older adults to participate in decision making bodies, such as community councils or committees
n. Easy-to-find information about local volunteer opportunities

* 23. Which of the following best describes your current employment status?

* 24. If employed, how likely is it that you will retire?

* 25. Does the City/Town where you live have the following?

 
a. A range of flexible job opportunities for older adults
b. Job training opportunities for older adults who want to learn new job skills within their job or get training in a different field of work
c. Jobs that are adapted to meet the needs of people with disabilities

* 26. Would you turn to the following resources if you, a family member or friend needed information about services for older adults, such as caregiving services, home-delivered meals, home repair, medical transport or social activities? (CHECK ALL THAT APPLY)

* 27. Does the City/Town where you live have the following?

 
a. Access to community information in one central source
b. Clearly displayed printed community information with large lettering
c. An automated community information source that is easy to understand, such as a toll-free telephone number
d. Free access to computers and the Internet in public places, such as the library, senior centers or government buildings
e. Community information that is delivered in person to people who may have difficulty or may not be able to leave their home
f. Community information that is available in a number of different languages

* 28. Do you have dental insurance?

* 29. Have you had a dental exam in the last 3 years?

* 30. Have you had a flu shot in the last year?

* 31. In case of an emergency, do you have a plan to evacuate?

* 31a. Would you like help in creating a plan?

* 32. In case of a major disaster, do you have a plan, including having basic supplies, water, contact information, etc.?

* 32a. Would you like help in creating a plan?

* 33. Have you prepared a supply of your prescription medications to have on hand in the event of a disaster?

* 34. Are you or someone else in your home caring for family members or friends who are experiencing problems with memory/thinking that is affecting their ability to work or live a normal life?

* 34a. If “YES”, have they been diagnosed with Alzheimer’s or another type of dementia by a doctor? If “NO”, please go to the next question.

* 34b. If “YES” to either question above, please tell us what kind of help you feel might be useful? If “NO”, please go to the next question.  (CHECK ALL THAT APPLY):

ABOUT YOU…

* D1. Are you male or female?

* D2. Do you think of yourself as…(CHECK ALL THAT APPLY)

* D3. What year were you born?

* D4. What is your current marital status?

* D5. Do you live alone?

* D5 a. If "NO", how many people regularly live in your household? If “YES”, please go to the next question.

* D5 b. If “NO” to D5, are you currently living with… (CHECK ALL THAT APPLY)

* D5 c. If “NO” to D5, are you a family caregiver?

* D5 d. If “YES” to D5 c, are you a caregiver for… (CHECK ALL THAT APPLY)

* D6. Do you have any of the following kinds of health care coverage?

 
a. Insurance through a current or former employer of yours or your spouse
b. Insurance purchased directly from an insurance company (not through an employer)
c. Medicare (for people 65 and older or people with certain health disabilities)
d. Medicaid [Medi-Cal] or any kind of government assistance plan for those with low incomes or a disability
e. Veterans Administration or other military health care
f. Any other insurance coverage

* D7. Does any disability, handicap, or chronic disease keep you and/or your spouse or partner from fully participating in work, school, housework or other activities? (CHECK ONLY ONE)

* D8. Are you of Hispanic, Spanish, Latino origin or descent?

* D9. Which language do you prefer to speak at home? (CHECK ONLY ONE)

* D10. What is your race and/or ethnicity? (CHECK ALL THAT APPLY)

* D11. What is the highest level of education you have completed?

* D12. Are you registered to vote?

* D13. In general, how often do you go online to access the Internet for things like sending or receiving e-mail, getting news and information, paying bills or managing finances, or buying products or services? This includes access from home, work, a mobile device (such as a smartphone), or someplace else.

* D14. What was your annual household income before taxes in the most recent tax year?

* Please use the space below for any additional comments

Thank you very much for completing this survey.
Your assistance in providing this information is greatly appreciated.
Report a problem

T