Southern Maryland Tri-County Survey: Community for Life

Are you 60 years or older and still living in your own Home? If so, we want to hear from you!
This survey will provide useful information for the southern Maryland Tri-county planning group as we consider initiating a Community for Life program in St Mary's, Charles, and Calvert Counties.

Maryland Community for Life SM is an innovative program developed by the Maryland Department of Aging to support older adults as they age at home. All members must be 60 years or older and be residents of the Tri-County area There are no health or income qualifications for the program.

For a monthly fee of $200, Community for Life will provide the following services:
·      Service Navigation (2 hours) to include periodic check-in calls, help with locating and accessing local services and support (such as finding the right contractor to ensure you are not paying too much) as well as social opportunities in your community
·      Handy Man (4 hours) to include basic home maintenance (that does NOT require a licensed service person) such as tasks that require the use of a ladder, basic technology support, or tasks that are challenging because of mobility difficulties
·      Transportation (2 hours) provides door-to-door, round trip transportation to non-emergency medical appointments, pharmacy, grocery stores, and to run errands within a certain area of the county
·      Also include a FREE in-home assessment to determine the safety risks in your home.
Please note that services do NOT include health care or continuing care at home.

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* 1. Are you interested in receiving Service Navigation, Handy Man, and Transportation support for a monthly fee to enable you to remain living in your own home as you get older?

Yes

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* 2. Would you be willing to pay $200/month for this program?

Yes

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* 3. Please identify how interested you are with Service Navigation services

Very interested

Somewhat Interested

Not at all interested

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* 4. Please identify how interested you are in Handy Man services

Very interested

Somewhat interested

Not at all interested

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* 5. Please identify how interested you are in Transportation support

Very interested

Somewhat interested

Not at all interested

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* 6. Initially, 2 hours of transportation would be included in the monthly fee. Is this sufficient for your monthly needs?

Yes

If not, how many hours do you need per month?Other (please specify)

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* 7. What is the average distance per trip that you usually need? Choose one

1-5 miles

6-10 miles

15-20 miles

More than 20 miles

N/A

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* 8. Is 4 hours per month for Handy Man services sufficient to meet your needs?

Yes

If not, how many hours do you need?Other (please specify)

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* 9. Is 2 hours per month for Service Navigation sufficient to meet your needs?

Yes

If not, how many hours do you need?Other (please specify)

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* 10. What is your zip code or home address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 11. What is your age?

60-69

70-79

80-89

90+

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* 12. If you would like to be contacted, please provide your phone number or e-mail address

Name

Email Address

Phone Number