CENTRAL MIDLANDS AREA AGENCY ON AGING 2018 NEEDS ASSESSMENT Survey

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* The CMCOG AAA is conducting a region-specific needs assessment to determine the needs of seniors in the Central Midlands Region. Please take a moment and complete the survey so that the Area Agency on Aging can find ways to better serve seniors in our area.

ARE YOU CURRENTLY RECEIVING SERVICES FROM A SENIOR CENTER OR AREA AGENCY ON AGING?

YES

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* Section 1: Demographic Information

What county do you live in?

Richland

Lexington

Fairfield

Newberry

Zip Code (please specify)

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* What is your Gender?

Female

Male

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* What is your Race?

African American

Asisan

Hispanic

White

Other (please specify)

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* What is your Age?

Less than 40

41-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85 and older

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* What is your Marital Status?

Married

Living with partner

Widowed

Separated

Divorced

Single

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* What is your (Monthly) Income

$750 or Less

$751-$850

$851-$1,005

$1,006-$1,336

$1,337-$2,010

$2,011 or more

Unknown

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* How many live in your Household?

5 or more people living in the home

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* Section 2: Please check all the below items that you can relate to and are currently experiencing.

I have trouble keeping my home clean.

It is difficult for me to do my laundry due to lifting, folding and putting clothes away.

I cannot do yard work due to physical or medical conditions.

It is difficult for me to get to the grocery store, pharmacy and/or medical appointments.

I have trouble keeping up with paying my bills.

I need assistance with bathing, dressing and toileting.

I am concerned about falls or other accidents.

I need legal advice, but I cannot afford it.

Sometimes I feel lonely or sad, even isolated.

I can't go grocery shop or cook much so home delivered meals would be helpful.

I don't know where the closest senior center is located.

Sometimes I don't have enough food to eat.

I need to exercise more but I don't where to start.

I am responsible for taking care of a child or children under the age of 18.

I am taking care of one or more adults over the age of 60.

I have a serious problem with bugs in my house.

I have bed bugs and can't get rid of them.

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* Section 3: Please put a check by the items on the list below that you are concerned when it comes to your ability to remain independent at home.

I need safe and affordable housing.

I have difficulty paying for my prescription medicines.

My physical health is declining.

I have mental health issues that sometimes make it difficult for me to live on my own.

I am unable to make necessary repairs on my home due to the cost.

I am unable to read and understand all my mail.

I have problems keeping my paperwork in order and sometimes loose things.

My Insurance premium are a struggle to pay monthly.

I don't know how I could afford nursing home care when and if I need it.

I can't afford to pay for dental care.

I can't afford hearing aids.

I can't afford eyeglasses.

I have trouble finding a doctor or medical specialist near me.

I or someone close to me has a drug or alcohol problem.

I have to deal with challenging family issues that are stressful.

I do not have friends, neighbors or others that have a positive influence on my life.

I struggle to make ends meet on a monthly basis.

I struggle keeping my home warm or cool due to poor insulation, leaky windows and/or structural damage.

Other (please specify)

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* Section 4: Family Caregivers: Please answer the following questions below if you provide substantial care to a loved one over the age of 60 or to anyone who has been diagnosed with dementia.

Do you provide hands on care for a loved one? If no, skip questions 2-5.

Yes

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* How many hours a week do you provide direct hands on care?

0-9

10-20

21-29

30-39

40-49

50-59

60-69

70-79

80-89

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* How many people are you currently providing direct hands on care for?

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* Are you currently receiving funding from the Family Caregiver Support Program?

Yes

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* If so, would your loved one be able to remain at home without the support of the Family Caregiver Support Program?

Yes

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* Section 5: Senior Centers

Does your community have a Senior Center?

Yes

I don't know.

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* If Yes, do you attend?

Yes

If not, why not?

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* Section 1: Demographic InformationWhat county do you live in?

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* What is your Gender?

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* What is your Race?

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* What is your Age?

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* What is your Marital Status?

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* What is your (Monthly) Income

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* How many live in your Household?

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* Section 2: Please check all the below items that you can relate to and are currently experiencing.

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* Section 3: Please put a check by the items on the list below that you are concerned when it comes to your ability to remain independent at home.

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* Section 4: Family Caregivers: Please answer the following questions below if you provide substantial care to a loved one over the age of 60 or to anyone who has been diagnosed with dementia.Do you provide hands on care for a loved one? If no, skip questions 2-5.

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* How many hours a week do you provide direct hands on care?

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* How many people are you currently providing direct hands on care for?

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* Are you currently receiving funding from the Family Caregiver Support Program?

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* If so, would your loved one be able to remain at home without the support of the Family Caregiver Support Program?

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* Section 5: Senior CentersDoes your community have a Senior Center?

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* If Yes, do you attend?

* Section 1: Demographic Information

What county do you live in?

* Section 4: Family Caregivers: Please answer the following questions below if you provide substantial care to a loved one over the age of 60 or to anyone who has been diagnosed with dementia.

Do you provide hands on care for a loved one? If no, skip questions 2-5.

* Section 5: Senior Centers

Does your community have a Senior Center?