By completing the survey below, you help us knowing how to serve our community best.

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* 1. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 2. What is your gender?

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* 3. What is your gender identity?

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* 4. What is your race or ethnicity?

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* 5. Which of the following best describes your current relationship status?

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* 6. What is your age?

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* 7. What is your living situation?

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* 8. What is your monthly income level?

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* 9. Which of the following electronic devices do you use? (Please select all that apply.)

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* 10. What type of mobile telephone do you PRIMARILY use?

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* 11. Have you ever served in any branch of the United States military, or not?

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* 12. In which branch (or branches) of the United States military have you served? (Check all that apply)

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* 13. Does someone help you with your daily needs and health care?

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* 14. If someone helps you with your daily activities  and/or health care, is the person a member of your family?

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* 15. If someone helps you with your daily activities and/or healthcare, does that person live with you?

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* 16. Do you help someone with their daily activities and/or health care?

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* 17. If you help someone with their daily activities and/or health care, is that person a member of your family?

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* 18. If you help someone with their daily activities and/or health care, does that person live with you?

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* 19. I am concerned about the time and difficulty of taking care of someone.

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* 20. Do you or have you received help from any Agency, such as a nursing agency, social services agency, including housing, aging.

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* 21. For the following concerns, please pick the best answer for yourself.

  Not At All Concerned A Little Concerned Concerned Very Much
Being taken advantage of by telephone scams
Being taken advantage of by other scams
Being physically or emotionally abused
Being neglected 
Being robbed 
Being taken advantage of financially

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* 22. Have you made friends with a stranger over the phone in the last 6 months to 1 year?

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* 23. Are you afraid someone may steal from you?

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* 24. I am concerned about being able to stay in my home because of my health.

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* 25. I am concerned about being able to stay in my home because of my income.

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* 26. I would be interested in the following programs concerning my health: please select all that apply.

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* 27. For the following concerns, please pick the best answer for yourself.

  Not At All A Bit Concerned Very Concerned
About needing and being able to afford long term health care.
About the cost of my health care premiums
About the cost of my out of pocket expenses
About choosing a health care plan that meets my needs.
About a health care plan I can afford.
About understanding how to use my health care plan

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* 28. I can afford to pay for my medications?

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* 29. I have adjusted my medication dosages because I can't afford my medication.

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* 30. For the following concerns, please pick the best answer for yourself.

  Not At All Concerned A Bit Concerned Very Concerned
Paying household bills
Paying other bills, for example taxes
Keeping your home in good shape
Getting around your house inside safely
Getting around your house outside safely
Being alone or  isolated
Availability of Transportation
Getting health and other services I need
Finding an affordable place to live if I have to move
Having an affordable place to live

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* 31. Is there a Senior Center in your area?

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* 32. Do you attend a local senior center?

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* 33. How do you learn about current events? Check all that apply.

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* 34. Which services offered by the Huntingdon-Bedford-Fulton Area Agency on Aging, are you aware of?  Check all that you are familiar with.

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* 35. Do you have other concerns that we have not asked about that you would like to share?

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