Skip to content
NCIHA Elder Village Development Survey
Elder Village
1.
What is your Tribal Affiliation?
Maidu Indian of Berry Creek Rancheria
Guidiville Rancheria
Hopland Band of Pomo Indians
Kletsel Dehe Wintun Nation
Manchester Point Arena Band of Pomo Indians
Mooretown Rancheria of Maidu Indians
Redwood Valley Little River Band of Pomo Indians
Sherwood Valley Rancheria Band of Pomo Indians
Wilton Rancheria
Other (please specify)
None of the above
2.
Are you an Elder? (60+ years old)
Yes
No
3.
How likely are you to live in an NCIHA Elder Village?
Likely
Neutral
Unlikely
4.
Do you receive SSI/SSP?
Yes
No
5.
Do you receive any other forms of income? Select all those that apply.
Retirement
Part-Time Employment
Full-Time Employment
Rental Income (as a property owner)
Business Income (business owner)
In Home Supportive Services
Tips
Other (please specify)
None of the above
6.
Do you require accessibility in your home? (i.e. wheelchair access, grab bars, walk-in shower, etc.)
Yes
No
7.
What traditional and cultural features would you like to see incorporated into the new elder living space? (i.e. traditional plants/medicine, basket patterns, etc.)
8.
What supportive services would you like to see offered in the elder village? Select all that apply.
Healthcare services
Cultural activities
Transportation assistance
Social support programs
Nutritional support
Other (please specify)
9.
What are your needs for visitor and gathering space in the elder village? Select all that apply.
Picnic Area
Arbor
Patio
Recreation Room
Community Dining
Community Kitchen
Library
Community Garden
Other (please specify)
10.
What features would you like to see included in shared space within the Elder Village? Select all that apply.
Accessibility (i.e. grab bars, ramps, wheelchair access, etc.)
Public Transportation
Communal Space
Community Kitchen
Walking Paths
Maker's Space
Library
In-House Physical Therapy
Access to Healthy and Traditional Foods
Community Delivery Services
Grocery Delivery Services
Pharmacy Delivery Services
Visitor Use Space (i.e. play equipment, picnic tables, patio, etc.)
Community Garden Space (i.e. seasonal fruits and vegetables, herbs, traditional medicine, etc.)
Other (please specify)
None of the above
11.
What are some features that you would like to see in the living space offered to Elder? Select all that apply.
Accessibility (i.e. grab bars, ramps, wheelchair access, walk-in shower, etc.)
Pet Friendly
Internet
Cable
Natural Lighting
Neutral Colors
Units that are Furnished
One-bedroom, one-bath
Two-bedrooms, one bath
Other (please specify)
12.
This space is saved for additional thoughts and comments. We value and thank you for your honesty and participation.
13.
If you are intersted in being added to our Elder Village waiting list, please provide your name and contact information. Thank you.
Name
Mailing Address
Email
Phone Number