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* 1. How would you rate your community as a place for people to live as they age? (This would be the geographical location where your home is located. A community can be located within a city or town or county.)

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* 2. What is the name of your community?

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* 3. What is your 5-digit ZIP code?

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* 4. How long have you lived in this community?

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* 5. How long have you lived in your county?

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* 6. Some people reside in places outside or their state for part of the year. Which of the following describes how you reside in your state? [CHECK ONLY ONE]

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* 7. Thinking about your retirement years when you do not work at all for pay, how likely is it that you will move to a different home in your community?

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* 8. Thinking about your retirement years when you do not work for pay, how likely is it that you will move to a different home outside of your community?

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* 10. How important is it for you to remain in your community as you age?

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* 11. Do you own or rent your primary home — or do you have some other type of living arrangement, such as living with a family member or friend?

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* 12. What type of home is your primary home?

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* 13. How important is it for you to be able to live independently in your own home as you age?

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* 22. In general, when compared to most people your age, how would you rate your health?

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* 23. How often do you engage in some form of physical exercise (such as walking, running, biking, swimming, sports, strength training, yoga, stretching)?

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* 24. How important is it to you to remain physically active for as long as possible?

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* 27. About how frequently do you interact with your friends, family or neighbors in your community? This interaction could be by phone, in person, email or social media (such as Facebook).

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* 28. Where do you typically go for continuing education or self-improvement classes/workshops in your community? [CHECK ALL THAT APPLY]

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* 33. Which of the following best describes your current employment status?

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* 34. How likely is it that you will continue to work for as long as possible, rather than choosing to retire and no longer work for pay?

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* 40. Are you male or female?

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* 41. What is your age as of your last birthday? [AGE IN YEARS]

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* 42. What is your current marital status?

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* 43. Are you or your spouse currently a member of AARP?

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* 46. Does any disability, handicap, or chronic disease keep you and/or your spouse or partner from fully participating in work, school, housework or other activities? [CHECK ONLY ONE]

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* 47. Are you of Hispanic, Spanish, Latino origin or descent?

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* 48. If you are Hispanic or Latino, please indicate which one best represents the language (s) you speak at home. [CHECK ONLY ONE]

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* 49. What is your race and/or ethnicity? [CHECK ALL THAT APPLY]

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* 50. What is the highest level of education you have completed?

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* 51. Thinking about state elections for [STATE] Governor and Legislators in the last five years, how often would you say you voted?

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* 52. Do you consider yourself to be a Democrat, a Republican, an Independent or something else?

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* 53. In general, how often do you go online to access the Internet for things like sending or receiving email, getting news and information, paying bills or managing finances or buying products or services? This includes access from home, work, a mobile device (such as a smartphone), or someplace else.

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* 54. What was your annual household income before taxes in the most recent tax year?

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* 55. Please use the space below for any additional comments.

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