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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.
1.What is your zip code?
2.What county do you live in?
3.What is your primary race?
4.What is your ethnicity?
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 / Time
6.Would you describe yourself as any of the following?
7.What is your gender identity?
8.Are you a military veteran?
9.What is your employment status?
10.Using the chart below, is your yearly income above or below the amount listed for family size?
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.
12.I have contacted the Central Illinois Agency on Aging/Age Central in the last?
13.I am familiar with the vision and mission of the Central Illinois Agency on Aging/Age Central
14.Please place a check mark next to our funded community providers that you are familiar with.
15.Are there any other services you feel would be beneficial for older adults and /or caregivers?