Area Plan Feedback Questionnaire

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:

years

months

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* 3. Birth Date or Age:

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* 4. Gender:

Male

Female

Transgender

Decline to State

Other (please specify):

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* 5. Marital Status:

Single (never married)

Married

Domestic Partner

Separated

Divorced

Widowed

Decline to State

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* 6. Sexual Orientation:

Heterosexual

Bisexual

Gay

Lesbian

Decline to State

Not listed (please specify)

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* 7. Education (highest grade level completed):

0-8th Grade

9-12th Grade

Some College

College Degree

Post Graduate Degree

Decline to State

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* 8. Impairments:(Check all that apply)

Physical (e.g. hearing, vision, mobility)

Cognitive (e.g. Dementia, Alzheimer’s)

Decline to State

None

Not listed (please specify)

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* 9. Employment:

Full Time

Part Time

Unemployed

Retired

Seeking Part Time Employment

Seeking Full Time Employment

Decline to State

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* 10. Living Arrangement:

Alone

With Others

Decline to State

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* 11. Living Quarters:

House

Condominium/Townhouse

Apartment

Mobile Home/Trailer

Hotel

Boarding House/Board and Room

Board and Care/Residential Home

Assisted Living Facility

Shelter

Not listed (please specify)

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* 12. Are you currently in a caregiver role?

Yes, for an Older Adult (60+)

Yes, for an Adult (18-59)

Yes, for a Child (17 and under)

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* 13. Race:

White

Black or African American

American Indian/Alaska Native

Other Race

Multiple Race (please check all that apply)

Decline to State

Asian Indian

Cambodian

Chinese

Filipino

Japanese

Korean

Laotian

Vietnamese

Other Asian

Guamanian

Hawaiian

Samoan

Other Pacific Islander

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* 14. Ethnicity:

Not Hispanic/Latino

Hispanic/Latino (if yes, check one below)

Mexican, Mexican American

Puerto Rican

Cuban

Decline to State

Not listed (please specify)

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* 15. Primary Language:

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

Newspaper(s)

Online/Internet (computer)

Mailings

Radio Station(s)

Television Station(s)

Other sources (please specify)

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

Yes. If yes, where?

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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?

Yes. If yes, where?

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

Yes. If yes, where?

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

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

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

Other (please specify)

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

The first problem is:

This is a problem to me because:

The second problem is:

This is a problem to me because:

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

Yes

Decline to State

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

Yes

Decline to State

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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?)

Yes

Decline to State

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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?)

Yes

Decline to State

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

Yes

Decline to State

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

Yes

Decline to State

Don’t know

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* 31. Do you use public transportation?

Yes

Decline to State

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

1-4 times

5-10 times

More than 10

Decline to State

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

Accessibility (getting to the stop or station—too far, no sidewalks, highways to cross)

Difficulty getting on or off the bus

Difficulty getting information about fares, routes, and schedules

Public transportation takes too long

Public transportation doesn’t go where I need to go

There is no public transportation where I live

Can’t afford

None of the above

Other (please specify)

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

Walk

Bike

My own vehicle

Relatives

Friends

Paratransit (e.g. MTS Access, NCTD LIFT)

Public Transportation (e.g. Bus, Trolley, Train) 0 Taxi 0 Community Org (e.g. FACT, On-the-Go, Seniors a GoGo, etc.)

Ride App (e.g. Lyft, Uber)

Decline to state

None Available

Other (please specify)

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

Walk with No Assistance

Walk with Assistance (e.g. cane, walker

Mobility scooter

Wheelchair

Decline to State

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

Desktop computer

Laptop computer or Netbook

iPhone, Android, Blackberry, or other smartphone

Regular cell phone (not including iPhone or other smartphones)

E-reader such as Amazon’s Kindle or Barnes and Noble’s Nook

iPad or other tablet computer

Wearable device such as a Fitbit, Garmin, or Apple Watch

Home assistant such as an Amazon Echo (e.g. Alexa or Google Home)

Smart home technology/security like a front-door monitor, thermostat, or fall-detection sensor (e.g. Nest, Ring, SimpliSafe)

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

Cost

Security and privacy concerns

Lack of familiarity with the new technology

Lack of confidence

Overwhelmed with the pace of technology changes

Frustration learning to use new technology

Doubt about the usefulness of new technology

Lack of technical support when needed

Vision

Fine motor difficulties (e.g., difficulty using touch screens or holding devices)

Hearing loss

No one to teach you/ teach too fast for understanding

None