Thank you for participating in Areawide Aging Agency's Needs Assessment Survey.  The following information helps us to develop our four year area plan by providing us information about needs for services for individuals 60 and over in Canadian, Cleveland, Logan, and Oklahoma Counties.

* 1. Do you consider yourself to be:

* 2. What is your age range?

* 3. What is your gender?

* 4. Which do you consider yourself to be:

* 5. In which county do you reside:

* 6. Do you depend on others to meet your transportation needs?

* 7. If yes, who provides your transportation?

* 8. When you receive a ride, what is your most likely destination? (Check all that apply)

* 9. Do you prepare your own meals?

* 10. For the meals you don't prepare, who prepares your meals for you?

* 11. Do you receive home delivered meals from a senior meal program?

* 12. Do you attend a senior meal site?

* 13. Are you able to afford all of the food you need?

* 14. If no, how many meals do you eat a day?

* 15. What is your current living arrangement?

* 16. If you live alone, how often do you engage in the following activities?

  Weekly Monthly Less Often
Visit or eat with family/friends
Attend religious services/activities
Group Activities or entertainments (cards, board games, movies etc.)
Nutrition Site

* 17. How do you communicate with family and friends? Select all that apply.

* 18. Area you able to do the light housekeeping it takes to keep your home clean and safe, which would include vacuuming, changing bed sheets, dishwashing, cleaning bathrooms, etc.

* 19. If no, who performs these duties for you?

* 20. What modifications would you need in order to stay in your home? Check all that apply.

* 21. Are you a grandparent who is primarily responsible for raising a grandchild?

* 22. If yes, how many grandchildren are you raising?

* 23. Are you currently a caregiver for a senior adult? (This would include a spouse.)

* 24. If yes, indicate your caregiving situation below.  Check all that apply.

* 25. Does the one you care for receive any of the following services from any source? Check all that apply.

* 26. Please complete the following if you are 60 years of age or older. Indicate which of the following services are very important, important, or not important to you. 
Note:  If you are an Aging Professional, please move to question 30.

  Very Important Important Not Important
Home Delivered Meals
Congregate Meal Program (Senior meal sites)
Housekeeping (Homemaker)
Transportation
Nutrition Education
Nutrition Counseling with a Registered Dietician
Legal Service
Information and Assistance
Ombudsman Services
Advocacy

* 27. Please complete the following if you are 60 years of age or older.  Indicate which of the following services are very important, important or not important to you.
Note:  If you are an Aging Professional, please go to question 30.

  Very Important Important Not Important
Help with Grandparents Raising Grandchildren
Caregiving Skills
Adult Day Care
Care Coordination (Case Management)
Home Health
Medication Management
Support Groups
Respite from Caregiving
Home Repair
Health Screenings/Vaccinations
Outreach (Referrals)

* 28. Are you currently receiving any of these services?

  Yes No
Home Delivered Meals
Congregate Meals (senior meal sites)
Housekeeping (Homemaker)
Nutrition Education
Nutrition Counseling with a Registered Dietician
Legal Service
Information and Assistance
Ombudsman Services

* 29. Are you currently receiving any of these services?

  Yes No
Help with Grandparents Raising Grandchildren
Caregiving Skills
Adult Day Care
Care Coordination (Case Management)
Home Health
Medication Management
Support Groups
Respite from Caregiving
Home Repair
Health Screenings/Vaccinations
Outreach (Referrals)

* 30. For Aging Professionals Only
Please indicate those services your clients need, but the services are not available or there are waiting lists.

  None Available Waiting List NA
Congregate Meals (senior meal sites)
Home Delivered Meals
Transportation to Medical Appointments
Transportation to grocery/prescriptions, etc.
Transportation to events such as church, hairdresser, clubs, community activities
Housekeeping (Homemaker)
Case Management
Home Modification/Repair
Chore Services (Lawn care, shopping, etc.)
Legal Aid
Access to low cost technology and/or training.

* 31. For Aging Professionals Only
Please indicate those services your clients need, but the services are not available or there are waiting lists.

  None Available Waiting List
Respite for caregivers
Home Care for seniors
Long Term Care options
Senior Housing options
Adult Day Care
Rehabilitation
Counseling/Mental Health Services
Addiction Services 
Abuse Protection

T