Aging & Independence Services (AIS) is requesting input from older adults and those interested in issues affecting older adults in San Diego County. We are updating our Area Plan – a four-year planning document required by the Older Americans Act which funds local programs for seniors. The information we collect is important for planning purposes and will guide us as we provide services and develop programs for older adults. Please share your thoughts below and help shape the future of services for older adults in San Diego County. All collected information is kept confidential.

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* 1. The town/city that I live in or zip code:

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* 2. I have lived in this community for:

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* 3. Birth Date or Age:

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* 4. Gender:

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* 5. Marital Status:

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* 6. Sexual Orientation:

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* 7. Education (highest grade level completed):

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* 8. Impairments:(Check all that apply)

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* 9. Employment:

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* 10. Race:

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* 11. Ethnicity:

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* 12. Primary Language:

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* 13. Living Arrangement:

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* 14. Living Quarters:

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* 15. Are you currently in a caregiver role?

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* 16. How do you get information that you need? (Check all that apply.)

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* 17. Before today, had you heard of Aging & Independence Services?

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* 18. If you are familiar with Aging & Independence Services, which programs/services have you used or referred to someone else?

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* 19. Before today, had you heard of the AIS Call Center?

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* 20. Have you heard of 2-1-1?

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* 21. Below is a list of activities that are difficult for some people. Check the boxes that best describes how difficult each activity is for you.

  1 - Independent 2 - Some Physical Assistance 3 - Lots of Physical Assistance 4 - Dependent Decline to State
Eating
Bathing
Dressing
Toileting
Transferring in/out of bed
Walking
Dressing
Meal preparation
Shopping
Managing medications
Managing money/paying bills
Using telephone
Heavy housework
Light housework
Yard/garden work
Home repairs/maintenance
Transportation

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* 22. For each activity with which you have difficulty, check who helps you with that activity. Only answer the items for which you need help. If you do not need help with any given activity, leave the row blank. (For example, your daughter is paid to assist you with “eating,” check the “paid worker” box.)

  Spouse/Partner Other Relative Non-Relative Agency Volunteer Paid Worker No One Decline to State
Eating
Bathing
Getting to the bathroom
Getting in and out of bed
Walking
Dressing/undressing
Preparing meals
Shopping
Managing medication
Managing money
Using the telephone
Doing heavy housework
Doing light housework
Transportation ability

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* 23. Below is a list of issues/conditions/concerns, which could affect an individual's quality of life. Check the box which best describes how much each one is a problem for you.

  No Problem Minor Problem Serious Problem
No Problem
Minor Problem
Serious Problem
Accidents n/out of the home (e.g. falling)
Crime
Depressed mood
Employment
Energy/utilities
Health care
Household CHORES
Housing
Isolation
Legal affairs
Loneliness
Money to live on
Obtaining information about services/benefits
Enrolling/applying for services/benefits
Taking care of a child under 18 years of age
Taking care of an adult

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* 24. The two problems from Question 23 that affect me the most are: 

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* 25. At the end of each month do you have enough money to purchase food for balanced meals?

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* 26. Are you able to drive to the grocery store, shop for food and carry the bags of groceries home?

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* 27. Are you physically able to cook nutritionally balanced meals? (For example: Can you stand by the stove to cook food?)

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* 28. Do your household appliances function properly? (For example: Does your refrigerator hold cold temperatures? Do your oven and stove elements heat correctly?)

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* 29. Have you unintentionally lost or gained 10 pounds in the last 6 months?

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* 30. Do you have public transportation available in your area or community?

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* 31. Do you use public transportation?

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* 32. If yes, how often have you used public transportation in the past month?

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* 33. Are any of the following issues barriers for you? (Check all that apply)

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* 34. In general, when you need to get somewhere how do you usually get there?

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* 35. Please choose what applies for you to be mobile.

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* 36. Which of the following items do you have/own?

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* 37. In the past, which of the following have you experienced as a barrier to using new technology?

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