Central Illinois Agency on Aging (CIAA)/Age Central

We want your feedback!

This survey will take approximately 6 minutes to complete. CIAA uses this information to determine the most important needs in our community. We appreciate your input.

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* 1. What is your zip code?

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* 2. What county do you live in?

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* 3. What is your primary race?

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* 4. What is your ethnicity?

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* 5. What is your date of birth? We are primarily looking for Month and Year. To maintain anonymity you may enter 01 for DD.

Date

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* 6. Would you describe yourself as any of the following?

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* 7. What is your gender identity?

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* 8. Are you a military veteran?

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* 9. What is your employment status?

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* 10. Using the chart below, is your yearly income above or below the amount listed for family size?

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* 11. How much do you agree or disagree with the following statements?

  Strongly Disagree Disagree Neither agree nor disagree agree strongly agree
I can easily access healthcare services
I understand my healthcare coverage
I can easily access healthy food options
I have access to public transportation
I have enough opportunities to socialize
I know agencies that can help me stay in my home if needed.
I know where to go if I need counseling or emotional support.

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* 12. I have contacted the Central Illinois Agency on Aging/Age Central in the last?

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* 13. I am familiar with the vision and mission of the Central Illinois Agency on Aging/Age Central

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* 14. Please place a check mark next to our funded community providers that you are familiar with.

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* 15. Are there any other services you feel would be beneficial for older adults and /or caregivers?

T