Needs Assessment

We appreciate your responses to the following questions so that we can best determine how to allocate funding for services to help seniors in our nine county planning and service area of Eastern Idaho.

* 1. What city do you live in?

* 2. What  county do you live in?

* 3. What is your gender?

* 4. What is your age?

* 5. Are you a veteran?

* 6. Are you the spouse of a veteran?

* 7. Are you:

* 8. Is your income:

* 9. How many people, including yourself, live in your household?

* 10. Who lives with you? (Check all that apply)

* 11. Are you retired?

* 12. Do you have ongoing, adequate access to food?

* 13. Do you NEED HELP with any of the following activities? (Mark all that apply)

* 14. If assistance is needed, and you are not receiving it, is it because: (Mark all that apply)

* 15. Does SOMEONE YOU KNOW NEED HELP with any of the following activities? (Mark all that apply)

* 16. If assistance is needed, and they are not receiving it, is it because: (Mark all that apply)

* 17. If you needed assistance, is there someone you could call for help?

* 18. Do you provide unpaid care for one or more family members or friends on a regular basis?

* 19. If you do provide unpaid care, whom do you provide care for?

* 20. How many hours per week do you spend providing care for this person or these persons?

* 21. What kind of assistance could you use more help in within your caregiving duties? (Mark all that apply)

* 22. Does anyone in your household have behaviors due to: (Mark all that apply)

* 23. Have you, or anyone you know, been abused, neglected, or exploited?

* 24. Have you, or anyone you know, contacted Adult Protective Services?

* 25. How do you find out about community activities, events, and resources? (Mark all that apply)

* 26. For most of your trips, how do you travel? (Select only one)

* 27. Within the last 12 months, how often has it been difficult for you to arrange transportation for each of the following activities?

  Frequently Sometimes Never
Medical Trips
Shopping
Personal errands
Recreational or social trips

* 28. When you have trouble getting the transportation you need, what would you say are the reasons? (Check all that apply)

* 29. Do you use a computer at home?

* 30. Do you send and receive email?

* 31. Do you search the internet for information?

* 32. Do you go to your local Senior Center for meals or activities?

* 33. If so, what do you like about the Senior Center?

* 34. What suggestions do you have for the Senior Center? (If any)

* 35. If you do not go to the local Senior Center, why not?

* 36. Have you utilized assistance or support from one or more of the following services the Area Agency on Aging is able to offer within the last 12 months? (Mark all that apply)

* 37. Have you EVER utilized any of the following assistance or supports from any of the following services the Area Agency on Aging offers?  (Mark all that apply)

* 38. Any other comments you would like to make?

Thank you for taking the time to complete this survey! If you would like further information about the services available from the Area VI Agency on Aging, you may call us at 208-522-5391 or 1-800-632-4813 and speak to an Information and Assistance Specialist.
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