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KIPDA Region Community Needs Assessment Survey FY2021

Please complete the following questionnaire to help the KIPDA Area Agency on Aging & Independent Living identify needs for older adults, caregivers and those with disabilities. This information will help plan future services and programs. Please return the survey as soon as possible. All demographic and health related information will be kept confidential and is only used for statistical purposes.
1.Your county of residence is?
2.What is your zip code?
3.What is your age?
4.What is the gender of the person completing this form?
5.What is your race or ethnic background?
6.What is your current living situation? 
7.Please indicate your annual household level of income:
8.What is your marital status?
9.Level of school completed?
10.Are you a U.S. Military Veteran or Spouse of a Military Veteran?
11.Are you registered to vote?
12.Do you have the following? Check all that apply
13.What is your primary language?
14.Do you identify as having a disability or impairment? Check all that apply.
15.What type of transportation do you typically use? Check all that apply. 
16.If you were asked to contribute to the cost of transportation to get around, how much can you afford per round trip?
Current Progress,
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