Central Illinois Agency on Aging (CIAA)

We want your feedback!

This survey will take approximately 15 minutes to complete. CIAA uses this information to determine the most important needs in our community. We appreciate your input.

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* 1. Which Illinois County do you live in?

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* 2. What is your zip code?

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* 3. What is your primary race?

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* 4. What is your ethnicity?

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* 5. What is your gender identity?

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* 6. Which of the following best describes your current relationship status?

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* 7. What is your sexual orientation

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* 8. Using the Chart below, is your yearly income above or below the amount listed for your family size?

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* 9. What is your date of birth? We are primarily looking for Month and Year.  To maintain anonymity you may enter 01 for DD.

Date

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* 10. Do you have Medicare?

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* 11. Are you a veteran?

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* 12. How familiar are you with the following services for older adults in your area?

  Very Unfamiliar  Unfamiliar  Somewhat Familiar  Familiar 
A Matter of Balance (Fall Prevention) 
Adult Protective Services  (Elder Abuse)
Benefit Access Program (License plate discount/bus pass)
Congregate Meals
Home Delivered Meals 
Legal Services
Senior Health Insurance Program (SHIP) 
Transportation Services
Information and Assistance 
Long Term Care Ombudsman 
Reducing Social Isolation 
Adult Day Health Care 
Chore (shoveling snow, raking leaves etc) 
Dementia/Alzheimer's Services 
Financial Assistance for Daily Needs 
Grandparents Raising Grandchildren 
Homemaker for Daily Living and Personal Care 
Housing Options
New Technology Device Assistance 

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* 13. Have you received services from any of the following organizations? (Select all that apply)

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* 14. How much do you agree or disagree with the following statements?

  Strongly Disagree Disagree Neither agree nor disagree agree strongly agree
I can easily access healthcare services 
I understand my healthcare coverage
I can easily access healthy food options
I have access to public transportation
I have access to reliable internet
I can get where I need to go without any issues

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* 15. Do any of the following apply to you? (select all that apply)

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* 16. In the last 6 months: How often have you?

  Never  Rarely  Sometimes  Often Always 
Felt depressed 
Felt isolated 
Worried about .your finances 
Worried about your health
Worried about the health of a loved one
Worried about having a serious fall

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* 17. In an average week:  How often do you?

  0 days 1-2 days  3-4 days  5-6 days 7 days 
Leave the house
Socialize with others
Exercise 
Eat nutritionally balanced meals. 
Use public transportation

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* 18. Do you need assistance with tasks of daily living? (select all that apply)

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* 19. What other concerns do you have in relation to aging?

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