Older Americans Act: Needs Assessment

San Joaquin County designed this survey to analyze the needs of people 60 years and older and their caregivers to develop the provision of services.

Thanks!

Information and Assistance
209-468-1104

Question Title

* 1. The city/town I live closest to is:

Escalon

Lathrop

Lodi

Manteca

Ripon

Stockton

Tracy

Other (please specify)

Question Title

* 2. Please tell us a bit about you. Note: choose either Older Adult or Caregiver

	18 to 59 years	60 to 64 years	65 to 69 years	70 to 74 years	75 to 79 years	80 to 85 years	86 years and older
Older Adult	Older Adult 18 to 59 years	Older Adult 60 to 64 years	Older Adult 65 to 69 years	Older Adult 70 to 74 years	Older Adult 75 to 79 years	Older Adult 80 to 85 years	Older Adult 86 years and older
Caregiver	Caregiver 18 to 59 years	Caregiver 60 to 64 years	Caregiver 65 to 69 years	Caregiver 70 to 74 years	Caregiver 75 to 79 years	Caregiver 80 to 85 years	Caregiver 86 years and older

Question Title

* 3. Please indicate: 1) how the problem keeping older adults from being independent affects you personally or the person you take care, and 2) if you are receiving help or need help with that problem.

	No Problem - Not Applicable	Minor Problem	Serious Problem	Receiving Help	Need Help	No Help Needed
Caregiver for an Older Adult	Caregiver for an Older Adult No Problem - Not Applicable	Caregiver for an Older Adult Minor Problem	Caregiver for an Older Adult Serious Problem	Caregiver for an Older Adult Receiving Help	Caregiver for an Older Adult Need Help	Caregiver for an Older Adult No Help Needed
Caregiver for Grandchildren	Caregiver for Grandchildren No Problem - Not Applicable	Caregiver for Grandchildren Minor Problem	Caregiver for Grandchildren Serious Problem	Caregiver for Grandchildren Receiving Help	Caregiver for Grandchildren Need Help	Caregiver for Grandchildren No Help Needed
Caregiver Relief/Respite/Rest	Caregiver Relief/Respite/Rest No Problem - Not Applicable	Caregiver Relief/Respite/Rest Minor Problem	Caregiver Relief/Respite/Rest Serious Problem	Caregiver Relief/Respite/Rest Receiving Help	Caregiver Relief/Respite/Rest Need Help	Caregiver Relief/Respite/Rest No Help Needed
Crime Activity (fear or victim)	Crime Activity (fear or victim) No Problem - Not Applicable	Crime Activity (fear or victim) Minor Problem	Crime Activity (fear or victim) Serious Problem	Crime Activity (fear or victim) Receiving Help	Crime Activity (fear or victim) Need Help	Crime Activity (fear or victim) No Help Needed
Cutting the Front Lawn	Cutting the Front Lawn No Problem - Not Applicable	Cutting the Front Lawn Minor Problem	Cutting the Front Lawn Serious Problem	Cutting the Front Lawn Receiving Help	Cutting the Front Lawn Need Help	Cutting the Front Lawn No Help Needed
Dementia / Memory Loss	Dementia / Memory Loss No Problem - Not Applicable	Dementia / Memory Loss Minor Problem	Dementia / Memory Loss Serious Problem	Dementia / Memory Loss Receiving Help	Dementia / Memory Loss Need Help	Dementia / Memory Loss No Help Needed
Dental Care	Dental Care No Problem - Not Applicable	Dental Care Minor Problem	Dental Care Serious Problem	Dental Care Receiving Help	Dental Care Need Help	Dental Care No Help Needed
Disaster / Emergency Preparedness	Disaster / Emergency Preparedness No Problem - Not Applicable	Disaster / Emergency Preparedness Minor Problem	Disaster / Emergency Preparedness Serious Problem	Disaster / Emergency Preparedness Receiving Help	Disaster / Emergency Preparedness Need Help	Disaster / Emergency Preparedness No Help Needed
Elder Abuse	Elder Abuse No Problem - Not Applicable	Elder Abuse Minor Problem	Elder Abuse Serious Problem	Elder Abuse Receiving Help	Elder Abuse Need Help	Elder Abuse No Help Needed
Employment	Employment No Problem - Not Applicable	Employment Minor Problem	Employment Serious Problem	Employment Receiving Help	Employment Need Help	Employment No Help Needed
Energy / Utilities Costs	Energy / Utilities Costs No Problem - Not Applicable	Energy / Utilities Costs Minor Problem	Energy / Utilities Costs Serious Problem	Energy / Utilities Costs Receiving Help	Energy / Utilities Costs Need Help	Energy / Utilities Costs No Help Needed
Fear of Falling / Falling	Fear of Falling / Falling No Problem - Not Applicable	Fear of Falling / Falling Minor Problem	Fear of Falling / Falling Serious Problem	Fear of Falling / Falling Receiving Help	Fear of Falling / Falling Need Help	Fear of Falling / Falling No Help Needed
Feeling Alone	Feeling Alone No Problem - Not Applicable	Feeling Alone Minor Problem	Feeling Alone Serious Problem	Feeling Alone Receiving Help	Feeling Alone Need Help	Feeling Alone No Help Needed
Health Care Costs	Health Care Costs No Problem - Not Applicable	Health Care Costs Minor Problem	Health Care Costs Serious Problem	Health Care Costs Receiving Help	Health Care Costs Need Help	Health Care Costs No Help Needed
Home Safety: Grab Bars / Handrails	Home Safety: Grab Bars / Handrails No Problem - Not Applicable	Home Safety: Grab Bars / Handrails Minor Problem	Home Safety: Grab Bars / Handrails Serious Problem	Home Safety: Grab Bars / Handrails Receiving Help	Home Safety: Grab Bars / Handrails Need Help	Home Safety: Grab Bars / Handrails No Help Needed
Housing: Affordable / Available	Housing: Affordable / Available No Problem - Not Applicable	Housing: Affordable / Available Minor Problem	Housing: Affordable / Available Serious Problem	Housing: Affordable / Available Receiving Help	Housing: Affordable / Available Need Help	Housing: Affordable / Available No Help Needed
Information about Services	Information about Services No Problem - Not Applicable	Information about Services Minor Problem	Information about Services Serious Problem	Information about Services Receiving Help	Information about Services Need Help	Information about Services No Help Needed
Legal Affairs Assistance	Legal Affairs Assistance No Problem - Not Applicable	Legal Affairs Assistance Minor Problem	Legal Affairs Assistance Serious Problem	Legal Affairs Assistance Receiving Help	Legal Affairs Assistance Need Help	Legal Affairs Assistance No Help Needed
Medical Alert System	Medical Alert System No Problem - Not Applicable	Medical Alert System Minor Problem	Medical Alert System Serious Problem	Medical Alert System Receiving Help	Medical Alert System Need Help	Medical Alert System No Help Needed
Medicare Benefits Questions	Medicare Benefits Questions No Problem - Not Applicable	Medicare Benefits Questions Minor Problem	Medicare Benefits Questions Serious Problem	Medicare Benefits Questions Receiving Help	Medicare Benefits Questions Need Help	Medicare Benefits Questions No Help Needed
Medication: Safety and Effectiveness	Medication: Safety and Effectiveness No Problem - Not Applicable	Medication: Safety and Effectiveness Minor Problem	Medication: Safety and Effectiveness Serious Problem	Medication: Safety and Effectiveness Receiving Help	Medication: Safety and Effectiveness Need Help	Medication: Safety and Effectiveness No Help Needed
Money to Live	Money to Live No Problem - Not Applicable	Money to Live Minor Problem	Money to Live Serious Problem	Money to Live Receiving Help	Money to Live Need Help	Money to Live No Help Needed
Nutrition / Food	Nutrition / Food No Problem - Not Applicable	Nutrition / Food Minor Problem	Nutrition / Food Serious Problem	Nutrition / Food Receiving Help	Nutrition / Food Need Help	Nutrition / Food No Help Needed
Recreation / Exercise	Recreation / Exercise No Problem - Not Applicable	Recreation / Exercise Minor Problem	Recreation / Exercise Serious Problem	Recreation / Exercise Receiving Help	Recreation / Exercise Need Help	Recreation / Exercise No Help Needed
Transportation / Going Places	Transportation / Going Places No Problem - Not Applicable	Transportation / Going Places Minor Problem	Transportation / Going Places Serious Problem	Transportation / Going Places Receiving Help	Transportation / Going Places Need Help	Transportation / Going Places No Help Needed

Question Title

* 4. Below is a list of activities that older adults perform on a daily basis. Please indicate: 1) which best describes how difficult the activity is for you or the person you take care, and 2) if you are receiving help or need help with that activity.

	No Difficulty - Not Applicable	Minor Difficulty	Serious Difficulty	Receiving Help	Need Help	No Help Needed
Bathing	Bathing No Difficulty - Not Applicable	Bathing Minor Difficulty	Bathing Serious Difficulty	Bathing Receiving Help	Bathing Need Help	Bathing No Help Needed
Doing Heavy Housework	Doing Heavy Housework No Difficulty - Not Applicable	Doing Heavy Housework Minor Difficulty	Doing Heavy Housework Serious Difficulty	Doing Heavy Housework Receiving Help	Doing Heavy Housework Need Help	Doing Heavy Housework No Help Needed
Doing Light Housework	Doing Light Housework No Difficulty - Not Applicable	Doing Light Housework Minor Difficulty	Doing Light Housework Serious Difficulty	Doing Light Housework Receiving Help	Doing Light Housework Need Help	Doing Light Housework No Help Needed
Dressing	Dressing No Difficulty - Not Applicable	Dressing Minor Difficulty	Dressing Serious Difficulty	Dressing Receiving Help	Dressing Need Help	Dressing No Help Needed
Eating	Eating No Difficulty - Not Applicable	Eating Minor Difficulty	Eating Serious Difficulty	Eating Receiving Help	Eating Need Help	Eating No Help Needed
Getting In / Out of Bed	Getting In / Out of Bed No Difficulty - Not Applicable	Getting In / Out of Bed Minor Difficulty	Getting In / Out of Bed Serious Difficulty	Getting In / Out of Bed Receiving Help	Getting In / Out of Bed Need Help	Getting In / Out of Bed No Help Needed
Laundry	Laundry No Difficulty - Not Applicable	Laundry Minor Difficulty	Laundry Serious Difficulty	Laundry Receiving Help	Laundry Need Help	Laundry No Help Needed
Managing Money	Managing Money No Difficulty - Not Applicable	Managing Money Minor Difficulty	Managing Money Serious Difficulty	Managing Money Receiving Help	Managing Money Need Help	Managing Money No Help Needed
Preparing Meals	Preparing Meals No Difficulty - Not Applicable	Preparing Meals Minor Difficulty	Preparing Meals Serious Difficulty	Preparing Meals Receiving Help	Preparing Meals Need Help	Preparing Meals No Help Needed
Shopping	Shopping No Difficulty - Not Applicable	Shopping Minor Difficulty	Shopping Serious Difficulty	Shopping Receiving Help	Shopping Need Help	Shopping No Help Needed
Taking Medicine	Taking Medicine No Difficulty - Not Applicable	Taking Medicine Minor Difficulty	Taking Medicine Serious Difficulty	Taking Medicine Receiving Help	Taking Medicine Need Help	Taking Medicine No Help Needed
Using the Phone	Using the Phone No Difficulty - Not Applicable	Using the Phone Minor Difficulty	Using the Phone Serious Difficulty	Using the Phone Receiving Help	Using the Phone Need Help	Using the Phone No Help Needed
Walking	Walking No Difficulty - Not Applicable	Walking Minor Difficulty	Walking Serious Difficulty	Walking Receiving Help	Walking Need Help	Walking No Help Needed

Question Title

* 5. What is your household annual income? (Please choose from the dropdown menu by number of people in the household and corresponding annual income)

Question Title

* 6. What is your race/ethnicity?

	0-8th Grade	9th-12th Grade	Some College	College Degree	Graduate Degree	Decline to State
American Indian or Alaska Native	American Indian or Alaska Native 0-8th Grade	American Indian or Alaska Native 9th-12th Grade	American Indian or Alaska Native Some College	American Indian or Alaska Native College Degree	American Indian or Alaska Native Graduate Degree	American Indian or Alaska Native Decline to State
Asian or Asian American	Asian or Asian American 0-8th Grade	Asian or Asian American 9th-12th Grade	Asian or Asian American Some College	Asian or Asian American College Degree	Asian or Asian American Graduate Degree	Asian or Asian American Decline to State
African, African American, or Black	African, African American, or Black 0-8th Grade	African, African American, or Black 9th-12th Grade	African, African American, or Black Some College	African, African American, or Black College Degree	African, African American, or Black Graduate Degree	African, African American, or Black Decline to State
Hispanic, Latino, or Latinx	Hispanic, Latino, or Latinx 0-8th Grade	Hispanic, Latino, or Latinx 9th-12th Grade	Hispanic, Latino, or Latinx Some College	Hispanic, Latino, or Latinx College Degree	Hispanic, Latino, or Latinx Graduate Degree	Hispanic, Latino, or Latinx Decline to State
Pacific Islander	Pacific Islander 0-8th Grade	Pacific Islander 9th-12th Grade	Pacific Islander Some College	Pacific Islander College Degree	Pacific Islander Graduate Degree	Pacific Islander Decline to State
White or Caucasian	White or Caucasian 0-8th Grade	White or Caucasian 9th-12th Grade	White or Caucasian Some College	White or Caucasian College Degree	White or Caucasian Graduate Degree	White or Caucasian Decline to State
Decline to State	Decline to State 0-8th Grade	Decline to State 9th-12th Grade	Decline to State Some College	Decline to State College Degree	Decline to State Graduate Degree	Decline to State Decline to State

Please specify here if more than one race/ethnicity and/or other along with level of education:

Question Title

* 7. What is your highest level of education?

0-8th Grade

9-12th Grade

Some College

College Degree

Post Graduate Degree

Decline to State

Question Title

* 8. What is your gender?

Male

Female

Transgender Female to Male

Transgender Male to Female

Genderqueer/Gender Non-Binary

Decline to State

Other (please specify)

Question Title

* 9. What is your sexual orientation?

Straight/Heterosexual

Bisexual

Gay/Lesbian/Same Gender-Loving

Questioning-Unsure

Decline to tate

Other (please specify)

Question Title

* 10. Is there any other type of support that you, an older adult or caregiver, require or any other information you would like to share with us? If yes, please share:

Older Americans Act: Needs Assessment San Joaquin County designed this survey to analyze the needs of people 60 years and older and their caregivers to develop the provision of services.Thanks!Information and Assistance209-468-1104

Question Title

* 1. The city/town I live closest to is:

Question Title

* 2. Please tell us a bit about you. Note: choose either Older Adult or Caregiver

Question Title

* 3. Please indicate: 1) how the problem keeping older adults from being independent affects you personally or the person you take care, and 2) if you are receiving help or need help with that problem.

Question Title

* 4. Below is a list of activities that older adults perform on a daily basis. Please indicate: 1) which best describes how difficult the activity is for you or the person you take care, and 2) if you are receiving help or need help with that activity.

Question Title

* 5. What is your household annual income? (Please choose from the dropdown menu by number of people in the household and corresponding annual income)

Question Title

* 6. What is your race/ethnicity?

Question Title

* 7. What is your highest level of education?

Question Title

* 8. What is your gender?

Question Title

* 9. What is your sexual orientation?

Question Title

* 10. Is there any other type of support that you, an older adult or caregiver, require or any other information you would like to share with us? If yes, please share:

Older Americans Act: Needs Assessment

San Joaquin County designed this survey to analyze the needs of people 60 years and older and their caregivers to develop the provision of services.

Thanks!

Information and Assistance
209-468-1104