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

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* 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
Caregiver

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* 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 Grandchildren
Caregiver Relief/Respite/Rest
Crime Activity (fear or victim)
Cutting the Front Lawn
Dementia / Memory Loss
Dental Care
Disaster / Emergency Preparedness
Elder Abuse
Employment
Energy / Utilities Costs
Fear of Falling / Falling
Feeling Alone
Health Care Costs
Home Safety: Grab Bars / Handrails
Housing: Affordable / Available
Information about Services
Legal Affairs Assistance
Medical Alert System
Medicare Benefits Questions
Medication: Safety and Effectiveness
Money to Live
Nutrition / Food
Recreation / Exercise
Transportation / Going Places

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* 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
Doing Heavy Housework
Doing Light Housework
Dressing
Eating
Getting In / Out of Bed
Laundry
Managing Money
Preparing Meals
Shopping
Taking Medicine
Using the Phone
Walking

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* 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 
Asian or Asian American 
African, African American, or Black
Hispanic, Latino, or Latinx

Pacific Islander
White or Caucasian
Decline to State

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* 7. What is your highest level of education?

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* 8. What is your gender?

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* 9. What is your sexual orientation?

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* 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:

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