General Needs Survey Question Title * 1. Please indicate if you have ever used any of the following services: Elder Law Case Management Respite Care Personal or Attendant Care Adult Day Care Personal Emergency Devices Homemaker Services Minor Home Repair Transportation Services Medicare counseling services Other (please specify) OK Question Title * 2. Do you currently need help or have help with the following activities: Laundry Lawn and Yard Work Meal preparation Minor home repairs Major home repair and upkeep Regular housekeeping Shopping Transportation Bill Paying Other (please specify) OK Question Title * 3. In the next five to ten years do you anticipate needing help with the following activities? Laundry Lawn and Yard Work Meal preparation Minor home repairs Major home repair and upkeep Regular housekeeping Shopping Transportation Bill Paying Other (please specify) OK Question Title * 4. If you need assistance where do you go for help? Spouse Children Neighbors/Friends Church members Senior Centers Paid Help Area Agency on Aging Other (please specify) OK Question Title * 5. What positive things is your community doing for the older adult population? OK Question Title * 6. What else could/should your community be doing to better meet the needs of the older adult population? OK Question Title * 7. Have you heard of Jayhawk Area Agency on Aging before? Yes No OK Question Title * 8. As a Kansas Older Adult, which of the following needs are of concern to you or a likely to be of a concern? Maintaining personal independence Access to in-home care Expense of in-home care Access to transportation Help with housework/chores Access to homemaking services Maintain a healthy and complete diet Expense of food/groceries Access to employment Health Insurance/Medicare Counseling Access to heathy living services/information Advocacy for older adults in city, county, state, and federal government Access to long term care Expense of long term care Access to life-enrichment activities Help with financial issues Help with caregiver responsibilities Access to legal assistance and information Other (please specify) OK Question Title * 9. What is your Age range? Under 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90 90+ OK Question Title * 10. To which gender identity do you most identify? Male Female Transgender Female Transgender Male Prefer not to answer OK Question Title * 11. Marital status: Single Married Widowed Divorced Domestic Partnership Prefer not to answer OK Question Title * 12. Employment status (please mark all that apply): Retired Working full time Working part time OK Question Title * 13. Race (please mark all that apply): White Black/African American Native American Asian/Pacific Islander Other Prefer not to answer OK Question Title * 14. Are you of Hispanic or Latino ethnicity? Yes No OK Question Title * 15. Do you reside within your town’s city limits? Yes No OK Question Title * 16. Zip code: OK Question Title * 17. +4(optional) OK Question Title * 18. What is your household’s monthly gross income? OK Question Title * 19. How many people are in your household? (Include yourself, your spouse, and any dependents who may be claimed on tax returns) OK DONE